Dillard Dalmatians Bullying Report
Rockingham County Schools and Dillard Academy Administration and Staff are interested in knowing about any bullying that may be occurring for you, other students that you want to anonymously assist who are being bullied or as a parent concerned about your child's school safety. We want to make sure our students feel safe. 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 needs immediate attention please contact your student's Principal or counselor directly.
Today's Date *
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Your name (optional)
Your answer
Your telephone number and/or email address (optional)
Your answer
Are you a: *
Name of person(s) being bullied: *
Your answer
Student's Grade Level and Teacher *
Your answer
Name of alleged offender. *
Your answer
Alleged Offender's Grade Level and Teacher (if known)
Your answer
Is the alleged offender older or younger than the person being bullied? *
Date of the incident *
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Name of any other person that could have seen the incident and could provide more information. *
Your answer
Where did the incident occur (check all that apply) *
Required
Check the statement that BEST describes what happened:
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. *
To your knowledge, has this been reported before? *
If you answered "YES" to answer above, did someone respond within 24 hours? If not, did you follow up with a phone call to the administration of the school for assistance? If so, what was the outcome?
Your answer
Is there any additional information that you would like to provide? *
Your answer
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