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
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