Bullying Incident Report Form: Gallagher Middle School
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.  

*Please note that interpersonal conflicts can also be mediated by school support staff.  Please reach out to a school counselor or Mr. Gallivan for additional guidance and support.
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Name of Person Completing this Form (Please note, anonymous reports are more difficult to investigate and may not result in a response)
Email Address of Person Completing this Form
Phone Number for Person Completing this Form
I am a: *
Name of Alleged Victim *
Grade of Alleged Victim
Date of Incident (If multiple, most recent incident)
MM
/
DD
/
YYYY
Approximate Time of Incident (If multiple, most recent incident)
Time
:
Location of Incident/Incidents
List the name of the alleged aggressor/aggressors.  If name is not known, provide any other identifiable information:
Describe the incident and situation with as much detail as possible to help the person looking into the issue.
When and where did it happen?
Were there any witnesses?   If yes, who?
Any other pertinent information, including previous incidents or threats:
What sort of help would you like with this issue?
Submit
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