St. Luke Catholic School

San Antonio, TX

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Bullying Report Form

- Parent Resources

St. Luke Catholic School promotes a safe, positive and productive educational environment, prohibiting all forms of bullying. All students are to be treated with dignity and respect. If you wish to report an incident of alleged bullying, complete and submit the form below.

Definition:
Bullying-a single significant act or pattern of acts by one or more students directed at another student that exploits an imbalance of power and involves engaging in written or verbal expression, expression through electronic means, or physical conduct that occurs within or outside of school property, at a school-sponsored or school-related activity, or in a vehicle operated by the school or the Archdiocese of San Antonio and that:

1.	Has the effect or will have the effect of physically harming a student, damaging a student's property, or placing a student in reasonable fear of harm to the student's person or in reasonable fear of harm to the student's property; or
2.	Is sufficiently severe, persistent and pervasive enough that the action or threat creates an intimidating, threatening or abusive educational environment for a student.
3.	Materially and substantially disrupts the educational process or the orderly operation of a classroom or school; or
4.	Infringes on the rights of the victim at school.

BULLYING REPORT FORM

This form may be submitted anonymously

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- Optional Information
  
  Name of person reporting incident: Please enter valid data.
  
  Phone Number Please enter a phone number.
  
  Email Please enter an email address.
  
  I am a: student parent/guardian adult relative school staff member
- Required Information
  
  Student target's name REQUIRED Please fill out this field. Please enter valid data.
  
  Name of alleged offender(s): REQUIRED Please fill out this field. Please enter valid data.
  
  Date & time of incident(s) REQUIRED Please fill out this field. Please enter valid data.
  
  Location of incident(s) REQUIRED Please fill out this field. Please enter valid data.
  
  Describe the incident(s) as clearly as possible, including such things as: what force or physical contact, if any, was used; any hurtful verbal statements, threats, requests, or demands; and any electronic means used.
  
  Description of incident(s) REQUIRED Please fill out this field.
  
  Names of adult or student witnesses: REQUIRED Please fill out this field.
  
  Any additional information you would like to provide:
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