Maryland State Department of Education in accordance with the Safe Schools Reporting Act of 2005

Directions: Bullying, harassment, or intimidation are serious and will not be tolerated. This is a form to report alleged bullying, harassment, or intimidation that occurred on school property; at a school-sponsored activity or event off school property; on a school bus; or on the way to and/or from school, in the current school year. If you are a student target, the parent/guardian of a student target, or a close adult relative of a student target, or a school staff member and wish to report an incident of alleged bullying harassment, or intimidation, complete this form online and it will be emailed to the Principal at the student target’s school.   Contact the school for additional information or assistance at any time. A confirmation email will be sent to the email address entered on this form as a record of this report.

Bullying, harassment, or intimidation means intentional conduct, including verbal, physical, or written conduct, or an intentional electronic communication, that: (I) creates a hostile educational environment by substantially interfering with a student’s educational benefits, opportunities, or performance, or with a student’s physical or psychological well-being and is: 1. motivated by an actual or a perceived personal characteristic including race, national origin, marital status, sex, sexual orientation, gender identity, gender expression, religion, ancestry, physical attribute, socioeconomic status, familial status, or physical or mental ability or disability; or 2. threatening or seriously intimidating; and (II) 1. occurs on school property, at a school activity or event, or on a school bus; or 2. substantially disrupts the orderly operation of a school. Electronic communication means a communication transmitted by means of an electronic device, including a telephone, cellular phone, computer, or pager.

Mandatory fields are marked with an asterisk - *

Person Reporting Incident
The Incident
Information About the First Alleged Offender
Enter whatever information is known about this person
Information About the Second Alleged Offender
Enter whatever information is known about this person
Information About the Third Alleged Offender
Enter whatever information is known about this person
Date(s) Incident(s) Occurred
(At a minimum, the first date is required *)
(Retype your name as your signature) By signing this report form, I attest that all information on this form is accurate to the best of my knowledge and I understand the serious nature of this report. By signing this report form, I understand and agree to be contacted by school, local, state or federal authorities to assist in the matters of this report.
This information must be entered for the security of the site
Enter the characters shown in the image.