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James H. Eldredge School Bullying Reporting Form
For more information, please refer to the Bullying, Intimidation, & Harassment policy of East Greenwich schools:
tinyurl.com/EGpolicy
All sections are optional. The information you provide will be submitted directly to the principal of Eldredge.
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* Indicates required question
1. Name of the person filing this report:
Your answer
2. Who is being bullied?
Your answer
3. Who do you believe is bullying this person?
Your answer
4. What is the relationship between you and the alleged bully and the victim? How do you know them?
If names are unknown, please provide any other identifiable information.
Your answer
5. Please list all the students possibly involved.
If names are unknown, please provide any other identifiable information.
Your answer
6. Please provide a description of any specific bullying incidents involving the students noted in questions 2 & 3.
Your answer
7. When did these bullying incident/s occur?
Your answer
8. Where has the bullying occurred?
(Check all that apply)
Classroom
Cafeteria
Gym
Hallway/Stairs
Bathroom
Playground / Recess
Bus/Bus stop
Walking to school
Walking from school
School event
Online
Outside / Elsewhere on school premises
Other
9. If there were any possible witnesses, please list all their names.
Your answer
10. Type of bullying being reported:
*
(Check all that apply)
Physical
Social/Emotional (Slurs, innuendos, demeaning comments, etc)
Cyberbullying (use of technology)
Racial/Ethnic
Sexual
Gender-based
Disability-based
Other
Required
11. Who else have you reported this incident to, if anyone?
Your answer
12. Other information, including previous incidents or threats:
Your answer
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