Bullying Incident Report Form: LaPerche Elementary
Smithfield Public Schools investigation of allegations of alleged bullying and/or cyber-bullying. By submitting this form, your are certifying that all statements made in the complaint are true and complete. Any intentional false statement of fact will subject you to appropriate discipline. You authorize school officials to disclose the information that you provide only as necessary in pursuing the investigation.  
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Student Name *
Grade *
Date
MM
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DD
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YYYY
Time
Time
:
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?   If yes, who?
Other information, including previous incidents or threats:
Your name:
Email address/Phone number:
Submit
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