2. DERBY POLICE DEPARTMENT INSTRUCTIONS FOR REPORTING BULLYING
   The Derby Police Department supports USD 260 in creating a safe, friendly and fun environment where students want to learn. Reporting of bullying actions is essential to achieving that goal. In your report, please include all information you feel will be helpful. Required fields are marked with an asterisk (*). When you have completed the report, click “SUBMIT” at the bottom. This site is reviewed each week day. All information provided will be kept confidential. Your report will be reviewed by the Derby Police Department. Reports of bullying that occurs on USD 260 property or at a school-sponsored event will be forwarded to USD 260. IF THIS IS AN EMERGENCY, CALL 911 IMMEDIATELY! Our number one concern is student safety. Intentionally making a false report to the police is a crime. USD 260 students should always report bullying concerns to both school administration and a parent.
6. Victims Name
   First, Last
7. Victims School
   -- Select One --Derby High SchoolDerby Middle SchoolDerby North Middle SchoolDerby Hills ElementaryEl Paso ElementaryPark Hill ElementaryPleasantview ElementarySwaney ElementaryTanglewood ElementarySt. Mary's Catholic School
9. Has the appropriate teacher, coach, or bus driver been contacted?

   1. Yes
   2. No

   Check one
10. If yes, please list the name(s) of who you contacted.
    Separate with a comma.
12. Name(s) of Alleged Bully
    Separate with a comma.
13. Date of most recent incident
    Date of most recent incident
15. Did anyone witness the action?

    1. Yes
    2. No

    Check one
16. If yes, please list the name(s) of witness(s)
    Separate with a comma.
18. Where did the incident happen?

    1. On Campus
    2. Off Campus

    Check one
19. If on Campus please describe the location
21. Please select a statement that best describes what happened during the incident

    1. Hitting, kicking, shoving, other physical contact
    2. Getting another person to hit or harm the student
    3. Teasing, name calling, threatening, or other remarks
    4. Making rude and/or threatening remarks
    5. Excluding or rejecting the student in activity
    6. Spreading rumors or gossip
    7. Cyberbullying (Facebook, Twitter, social media, etc...)
    8. Sexual Harassment
    9. Other

    Check all that apply.
23. If other, please describe.
25. Why did this harassment or intimidation occur?
    Describe
27. What did the alleged bully say or do?
    Describe
29. Did a physical injury result from this incident?

    1. Yes
    2. No

    Check one
30. Is there any additional information you would like to provide?

    1. Yes
    2. No

    Check one
32. If yes, describe.
33. If yes, describe.
35. Today's Date
    Today's Date
37. Name of person reporting incident.
    First, Last (optional)
38. Email Address
    Optional
39. Phone Number
    Optional
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field