200 R.I. Code R. 200-RICR-30-10-2.13
REPORT FORM (SAMPLE) |
(Bullying and/or Cyberbullying) |
Name: ______________________________Student ID: _______________________ Grade: ______ |
Date: ______________ Time: _________ School: ___________________________________________ |
Please answer the following questions about this reporting incident: |
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? [] yes [] no If yes, who? |
Other information, including previous incidents or threats: |
Student or parent declines to complete this form: Initial: _________________ Date: ____________ |
I certify 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 school officials to disclose the information I provide only as necessary in pursuing the investigation. |
Signatures: |
Student: ___________________________________________ Date: ____________ |
School official receiving complaint: ______________________ Date: ____________ |
School official conducting follow-up: _____________________ Date: ____________ |
This document shall remain confidential |
200 R.I. Code R. 200-RICR-30-10-2.13