Riverton High School Bullying Incident Report

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In an effort to eliminate bullying in our schools, the Riverton School District encourages anyone to report incidents of bullying when appropriate. The Riverton School Board has defined bullying (including cyber-bullying) as "any severe or pervasive physical or verbal act or conduct, typically repetitive, including communications made in writing or electronically, directed toward a student or students" that has or can be reasonably predicted to have the effect of one or more of the following:

1. Placing the student or students in reasonable fear of harm to the student's or students' person or property;

2. Causing a substantially detrimental effect on the student's or students' physical or mental health;

3. Substantially interfering with the student's or students' academic performance; or

4. Substantially interfering with the student's or students' ability to participate in or benefit from the services, activities, or privileges provided by the school (7:220).

Thank you for completing this form. The Riverton School District appreciates your efforts in helping us to improve the learning environment for our students.

Your Name (Optional)

Date *

YYYY

You are a: *

Student

Parent

Staff Member

Other

Are you the target of the bullying or school violence that you are reporting? *

Yes

Indicate here if you prefer to remain anonymous.

Yes

Clear selection

Date of Incident *

YYYY

Time of Incident *

Time

Name of Person(s) Being Bullied? *

Name of Offender(s)? *

Bullying Witness *

Did you witness the incident?

Yes

Other Witness *

For how long has the bullying been occurring? *

Please report whether this is the first time or if it has been going on for a longer period of time (days, weeks, etc.)

Describe the incident(s), including what the alleged offender(s) said or did and the harm that was caused to the target: *

Was the incident based on any of these characteristics? *

Check all that apply

Race

Color

Nationality

Sex

Sexual orientation

Gender identity

Ancestry

Age

Religion

Physical disability

Mental disability

Homeless status

Parental status

Pregnancy

I don't know

Other

Required

If you answered the previous question as "Other", please explain.

Student(s) were targeted for bullying in the following way(s): *

Check all that apply

Electronic devices (e.g., internet, Social media platforms, text, email, cyberbullying,etc.)

Written communication (e.g., handwritten notes, other written documents, email, etc.)

Physical act or conduct (e.g., pushing, hitting, destruction of property, stalking, etc.)

Verbal act or conduct (e.g., rumors, lies, name-calling, using derogatory slurs, etc.)

Social (e.g. purposeful exclusion, causing psychological harm, etc.)

Items depicting implied hatred or prejudice were worn, possessed or displayed

Other

Required

If you answered the previous question as "Other", please explain.

Student(s) were targeted for bullying in the following place(s): *

Check all that apply

Classroom

Locker room

Hallway

Extracurricular activity

Cafeteria

Bus

Restroom

Bus stop

Gym

School related activity or event

Other

Required

If you answered the previous question as "Other", please explain.

Please tell us about the incident in your own words. Use as much detail as possible - what time did the incident(s) take place, who witnessed it, what was said, what types of interactions occurred (physical, written, social, electronic, etc.) *

The above information is true and accurate to the best of my knowledge. *

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