RCSD Bullying Incident Report

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If you have been the target of bullying or have witnessed the bullying of a Rankin County School District student, you may complete the form below. Information submitted will be forwarded to the building principal where the incident occurred during normal school operating hours. Reports of bullying will be investigated and disciplinary action will be taken if warranted.

You have the right to complete this form anonymously; however, it will be easier for the school to investigate this matter if as much information as possible is provided. By completing the form below, you are certifying that you are making a good faith & as truthful as you know report of bullying behavior. A complainant that knowingly falsely accuses someone could be subject to disciplinary and possible other legal action.

Email *

What is the difference between normal conflict & bullying behavior?

Today's Date *

YYYY

Your Name

Contact Phone Number

School Where Incident Occurred *

Check the box of the person reporting the bullying (the person who is filling this form out) *

Student

Parent

Staff

Administrator

Other

Required

Date of bullying incident *

YYYY

Name of person(s) subjected to alleged bullying *

Age of the target of alleged bullying *

Grade level of person subjected to alleged bullying *

Person(s) alleged to have committed the bullying behavior *

Age of person(s) alleged to have committed bullying *

Grade level of person(s) alleged to have committed bullying *

Where did the incident(s) of alleged bullying occur? Choose all that apply:

Column 1

On school property

On a school bus

At a school sponsored event/activity

online via technology

on the way to & from school

Other

Summarize the alleged incident(s) or occurrence(s) of bullying as accurately as possible. *

Did the alleged bullying behavior described above meet any of the following criteria? *

often repeated behavior

purposeful behavior

can be a serious threat of emotional or physical harm

strong emotional reaction from the target

alleged bully has no remorse- blames target

limited effort by alleged bully(s) to resolve the problem

Required

Names of Witnesses *

Is this the first incident you are aware of? *

Yes

Have you reported this to anyone else? *

Yes

Required

If you said yes above, please explain who you reported to

I certify that this report is being made in good faith and the details I have provided are true and accurate as far as my understanding. *

Yes

A copy of your responses will be emailed to the address you provided.

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