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Chariho Middle School Bullying Report Form 2022-2023
Please answer the following questions about this Bullying Reporting Incident
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Email
*
Your email
Student Name: (First Last)
*
Your answer
Student ID
Your answer
Student Grade Level:
*
Choose
5
6
7
8
Not Sure
Reporting Date
*
MM
/
DD
/
YYYY
Date of Incident:
*
MM
/
DD
/
YYYY
Report Time:
*
Time
:
AM
PM
School
Choose
Chariho Middle School
List the name of the alleged bully, and/or cyberbully. If name is not known, provide any other identifiable information.
Your answer
Relationship between you and the alleged bully, and or cyberbully:
Your answer
Describe the Incident:
*
Your answer
When and where did it happen?
Your answer
Were there any witnesses?
Yes
No
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If there were witnesses, who were they?
Your answer
Other information, including previous incidents or threats:
Your answer
By clicking the "submit" button you are certifying that all statements made in the complaint are
true and complete
. Any intentional false statement of fact will subject me to appropriate discipline. I authorize the school officials to disclose the information I provide only as necessary in pursuing the investigation.
A copy of your responses will be emailed to the address you provided.
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