Chariho High School Bullying Report Form 2022-2023
Please answer the following questions about this Bullying Reporting Incident
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Email *
Submission Statement
It is important to remember that referrals are part of the student’s discipline record.                
  • Please refrain from using the names of any other students involved with the incident. 
  • Please check your spelling and grammar before submitting.
Student Name: (First Last) *
Student ID
Student Grade Level: *
Reporting Date *
Date of Incident: *
Report Time:  *
List the name of the alleged bully, and/or cyberbully. If name is not known, provide any other identifiable information.
Relationship between you and the alleged bully, and or cyberbully:
Describe the Incident: *
When and where did it happen?
Were there any witnesses?
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If there were witnesses, who were they?
Other information, including previous incidents or threats:
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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