Rogers Online Bully Report Form

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IF YOU ARE IN IMMEDIATE DANGER, CALL 911.

Rogers Middle School is committed to providing a safe, comfortable learning environment for all students. Bullying incidents can be reported directly to a trusted staff member at Rogers. This online form may also by used by Rogers students to report being bullied or by someone witnessing a student being bullied.

Once submitted, the investigation process will begin within five (5) working days. Keep in mind, this process can only be as thorough as the information provided.

Email *

Date of incident: *

YYYY

Location of incident: *

Name *

Phone (optional)

Bullying Incident: Name(s) of alleged offenders

Describe the bullying incident. Try to include as many details as possible *

Check all that apply *

Name calling

Threat

Social Exclusion

Intimidation

Physical Violence

Public Humiliation

Unwanted Touching

Hazing

Other:

Required

Indicate if you think the incident was motivated by any of the following

To cause harm

To express bigotry/hatred

To feel superior

To show off to friends

Other:

FINAL SUBMISSION

By completing this form, you are verifying that your statements are true and accurate to the best of your knowledge.

Submit

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This form was created inside of Long Beach Unified School District.

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