RCMS Bullying Report Form V3

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Rockingham County Middle School is dedicated to ensuring that every student is a part of a safe and nurturing environment. We are interested in knowing about any bullying that may be occurring with or to our students. You may report this anonymously as a student, a parent, a teacher or as a concerned adult. This information is reviewed regularly during school hours. If you have added your contact information, please allow at least 24 hours for someone from the school to reply. If you responded anonymously, please add enough information for school staff to begin an investigation. If this is an emergency or something that needs immediate attention, please contact your student's Principal, Assistant Principal, or School Counselor directly.

1. Today's Date *

YYYY

2. Your name (optional)

3. Your telephone number and/or email address (optional)

4. Are you a: *

Parent

Student

Staff member

Other:

5. Name of student being bullied:

6. Name of alleged offender: *

7. Is the alleged offender older or younger than the person being bullied?

Same grade.

In an upper grade.

In a lower grade

At the high school.

Is a Teacher or Another Adult

Clear selection

8. Date of the incident *

YYYY

9. Name of any other person that could have seen the incident and could provide more information

10. Where did the incident occur (check all that apply) *

Classroom

Hallway

Bathroom

Gym/Lockerroom

Cafeteria

School sponsored event: athletic event,etc.

On the way to or from school

Bus

Social Media

Other:

Required

11. Check the statement that BEST describes what happened: *

Hitting, kicking, shoving, spitting, hair pulling, or throwing something

Getting another student to hit or harm the student(s)

Teasing, name-calling, making critical statements (racial comments, sexual orientation), or threatening a person or other means of communicating threats

Demeaning the victim and/or making jokes about the victim

Making rude and/or threatening gestures

Excluding or rejecting the student

Intimidating (bullying), extorting or exploiting

Spreading harmful rumors or gossip

Electronic Communication (please also select which type from below)

Texting

Social Networks: Facebook, Twitter, Instagram, Snap Chat

Webpostings

Blogs

Other:

Required

12. Does this meet the definition of bullying? Definition: Intentionally aggressive behavior, repeated over time and involves an imbalance of power. If so, provide more information. *

13. To your knowledge, has this been reported before? *

Yes

unsure

14. If you answered "YES" to question #13, did someone respond within 24 hours? If not, did you follow up with a phone call to administration of the school? If so what was the outcome?

15. Is there any additional information that you would like to provide? *

Submit

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