RFHS Anonymous Reporting Form

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NOTE: Information included in this form goes privately to the Campus Critical Incidence Response Coordinator. All submissions are reviewed and investigated.

The following form collects information on incidences of bullying, threats to the campus, sexual assault, sexual harassment, dating/domestic violence, or stalking. If you wish to report something not covered by these topics you may do so in the narrative section

If you would like to speak privately to someone, please call (361) 790-2220.

If this is an emergency situation, please ensure the safety of affected individuals before completing this form.

Your Name or Anonymous

Email Address

Phone Number

Today's Date *

YYYY

Affiliation with the Incident *

I am the victim/witness of the incident

I am a third-party (friend, sibling, parent, etc.)

Other:

Type of Incident(s) *

Dating/Domestic Violence

Non-Consensual Sexual Contact (Inappropriate Touching)

Sexual Harassment

Terroristic Threat (threat to campus, district, etc.)

Personal Threat (threat to harm you or another person)

Stalking/Cyberstalking

Other:

Required

Have you reported this incident to anyone else at Rockport-Fulton High School before today? *

Yes (please advise who you reported this incident to in the "other" section

No, but I have reported it to another person or agency

Other:

The following questions ask about the incident(s) that you are reporting. If any of the information is unknown, please leave the question blank.

Be as detailed as possible.

Victim's Name

Victim's Gender

Female

Male

Clear selection

Victim's Age

Date of Incident

Approximate Time of Incident

Victim's Affiliation with RFHS

Student

Teacher

Administrator

Other:

Clear selection

Include any additional relevant information you feel is important.

Alleged Perpetrator's Name

Alleged Perpetrator's Gender

Female

Male

Clear selection

Alleged Perpetrator's Age

Alleged Perpetrator's affiliation with RFHS

Student

Teacher

Administrator

Other:

Clear selection

Location of the Incident

On Campus (please add details in the "other" section)

Off Campus (please add details in the "other" section)

School Sponsored Event (field trip, athletic event, etc. --- provide details in "other" section)

Other:

Clear selection

How do the victim and alleged perpetrator know each other?

Provide a description of the incident (Who, What, When, How, & Why) *

Do you wish for a RFHS counselor or administrator to contact you?

Yes

Clear selection

Thank for your time and willingness to make RFHS a safe environment for education.

Submit

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