Russell County Schools - Bullying Report Form

In an effort to minimize antisocial behaviors in the school environment, the RCBOE has created a process whereby a student, parent, guardian, or bystander may report instances of bullying to the school administrator for further review and investigation. To report bullying, complete this form and it will be reported to the school. All reported incidents of bullying may be investigated, and when necessary, school administrators apply appropriate disciplinary consequences.

Intimidation means a threat or other action that is intended to cause fear or apprehension in a student, especially for the purpose of coercing or deterring the student from participating in or taking advantage of any school program, benefit, activity or opportunity for which the student is or would be eligible.

Bullying means a continuous pattern of intentional behavior that takes place on school property, on a school bus, or at a school-sponsored function including, but not limited to, cyberbullying or written, electronic, verbal, or physical actions that are reasonably perceived as being motivated by any characteristic of a student, or by the association of a student with an individual who has a particular characteristic.

Reporter Information

Your First Name *

Your Last Name *

You are a: *

Phone Number

Email Address

Have you previously submitted a report regarding this bullying? *

Have you contacted an adult regarding this issue? *

Incident Information

School related to incident *

Date of latest incident: * +

Name of victim(s): *

Name of alleged aggressor: *

Names of any witnesses: *

Location of incident: *

Type of incident: *

Behavior is related to: *

Student's perceived sexual orientation or gender identity

Student's religious beliefs

Student's racial or cultural background

Student's disability

Other: Other:

Please describe the incident and include as many details as possible: *

Did a physical injury occur from this incident? *

Did the victim miss school due to the incident? *

Signature of reporter: *

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