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Chariho Middle School Bullying or Cyber Bullying Report Report Form 2024-2025
Please answer the following questions about this Bullying Reporting Incident.
Please note: this report will remain confidential.
* Indicates required question
Email
*
Record my email address with my response
Name of individual who is submitting this form:
*
Your answer
Student First Name:
*
Your answer
Student Last Name:
*
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
Clear selection
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 .
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