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Richmond Regional High School - Bullying Report Form
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* Indicates required question
Name of person reporting (Can write 'anonymous').
*
Your answer
Position at the school.
*
Student
Staff Member
Parent
Other
Indicate your involvement.
*
Victim
Witness
Other
Date and Time of the incident.
*
MM
/
DD
/
YYYY
First and Last Name(s) of alleged Victim(s).
*
Your answer
First and Last Name(s) of alleged perpetrator(s).
*
Your answer
First and Last
Name(s) of any witnesses.
Your answer
Where did the incident occur?
*
In Class
Hallway
Outside
Online
Bus
Other
Required
Nature of the incident - Physical
(Check all applicable boxes).
Physical Assault (Punching, Kicking...etc)
Sexual Assault
Assult with a weapon
Verbal Harassment( Insult, Denigration...etc)
Blackmail, Extorsion, Threats
Sexual Orientation
Gender
Psychological
(Check all applicable boxes).
Verbal Harassment( Insult, Denigration...etc)
Blackmail, Extorsion, Threats
Social
(Check all applicable boxes).
Exclusion and/or Isolation
Spreading rumors
Property
(Check all applicable boxes).
Theft
Deliberately damaging personal or public property, graffiti...etc
Other
Cyberbullying
(Check all applicable boxes).
Posting sending or distributing a message, photo or Video
Filming or photographing someone without their knowledge
Coercing
Online harassment
Discrimination based on: (Check all applicable boxes)
Sexual Orientation
Gender
Physical or Mental Handicap
Weight/Size
Religion
Socio-Economic Status
Ethnicity
Race
Other
Description of the incident.
*
Your answer
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