Riverton Elementary School Bullying Incident Report
In an effort to eliminate bullying in our schools, the Riverton School District encourages anyone to report incidents of bullying when appropriate. The Riverton School Board has defined bullying (including cyber-bullying) as "any severe or pervasive physical or verbal act or conduct, typically repetitive, including communications made in writing or electronically, directed toward a student or students" that has or can be reasonably predicted to have the effect of one or more of the following:

1. Placing the student or students in reasonable fear of harm to the student's or students' person or property;

2. Causing a substantially detrimental effect on the student's or students' physical or mental health;

3. Substantially interfering with the student's or students' academic performance; or

4. Substantially interfering with the student's or students' ability to participate in or benefit from the services, activities, or privileges provided by the school (7:220).

Thank you for completing this form. The Riverton School District appreciates your efforts in helping us to improve the learning environment for our students.
Your Name (Optional)
Your answer
Date *
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You are a: *
Are you the target of the bullying or school violence that you are reporting? *
Indicate here if you prefer to remain anonymous.
Date of Incident *
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Time of Incident *
Time
:
Name of Person(s) Being Bullied? *
Your answer
Name of Offender(s)? *
Your answer
Bullying Witness *
Did you witness the incident?
Other Witness *
Your answer
For how long has the bullying been occurring? *
Please report whether this is the first time or if it has been going on for a longer period of time (days, weeks, etc.)
Your answer
Describe the incident(s), including what the alleged offender(s) said or did and the harm that was caused to the target: *
Your answer
Was the incident based on any of these characteristics? *
Check all that apply
Required
If you answered the previous question as "Other", please explain.
Your answer
Student(s) were targeted for bullying in the following way(s): *
Check all that apply
Required
If you answered the previous question as "Other", please explain.
Your answer
Student(s) were targeted for bullying in the following place(s): *
Check all that apply
Required
If you answered the previous question as "Other", please explain.
Your answer
Please tell us about the incident in your own words. Use as much detail as possible - what time did the incident(s) take place, who witnessed it, what was said, what types of interactions occurred (physical, written, social, electronic, etc.) *
Your answer
The above information is true and accurate to the best of my knowledge. *
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