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 Grade Level: *
Reporting Date *
Date of Incident: *
Report Time: *
Chariho High School/CharihoTech
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?
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.