Rhode Island Code of Regulations
Title 200 - Board of Education
Chapter 30 - DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION
Subchapter 10 - Civil Rights
Part 2 - Safe School Act - Statewide Bullying Policy (200-RICR-30-10-2)
Section 200-RICR-30-10-2.13 - Report Form (Sample)

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