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Hickory Creek Bullying Referral Form

Bullying is defined as a situation in which a student is exposed repeatedly and over time to negative actions on the part of one or more students. Negative actions can include inappropriate gestures, written statements, verbal remarks, or physical acts of aggression that place the student in reasonable fear of harm to his person or property, or that has the effect of insulting or demeaning any student in such a way as to interfere with their education.

Bullying most often will occur when a student asserts physical or psychological power over, or is cruel to, another student perceived to be weaker than they are for an ongoing period of time.

Bullying revolves around the basic premise that there is some imbalance of power between the aggressor and the victim. This can be either physical or psychological in nature. Therefore, conflicts and arguments that develop between friends or students of comparable social and physical standing do not fall in the arena of bullying. These situations need to be mediated and are met with consequences in accordance with the School Handbook, but they are typically not considered bullying-related incidences.

To report a bullying situation as described above, please complete the "Bullying Referral Form" below and submit. Hickory Creek Middle School appreciates your communication and support in ensuring the safety and welfare of all students.

Name *
Phone *
Are you a: *

Please Indicate the Grade of the student(s) involved *

6th Grade
7th Grade
8th Grade
Please provide the student(s) names if know

When did the incident occur

One Week Ago
More than a week ago
Please provdie a specific date if known

Where did the incident occur

Bus Stop
Locker Room
Do you consider the incident to be

Please describe the incident (include as much as you know)

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