RRHS Bullying Report Form

RRHS Bullying Report Form
Date of Report

Month Day Year
Date
Name of person reporting (Can write 'anonymous')
Position at the school (Circle)

Student Staff Member Parent Other
Indicate your involvement

Victim Witness Other
Date and Time of the Incident

Month Day Year
Date
Name(s) of alleged Victim(s)
Name(s) of alleged perpetrator(s)
Name(s) of any witnesses
Where did the incident occur

In class In the hallways Outside Online Other
Nature of the incident (Check all applicable boxes)
Physical

Physical Assault (punching Kicking etc) Sexual Assault Assault with a weapon
Psychological

Verbal Harassment (insult, denigration etc) Blackmail, extortion, threats
Discrimination based on:

Sexual orientation Gender Physical or Mental handicap Weight / size Religion Socio-economic status Ethnicity Race Other
Social

Exclusion and/or Isolation Spreading rumours
Cyberbullying

Posting, sending or distributing a message, photo, or video Filming or photographing someone without their knowledge Coercing or phishing online Online harassment
Property

Theft Deliberately damaging personal or public property graffiti, tags, etc Other
Description of the incident(s)
Date Submitted

Month Day Year
Date
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform