Dillard Dalmatians Bullying Report

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Rockingham County Schools and Dillard Academy Administration and Staff are interested in knowing about any bullying that may be occurring for you, other students that you want to anonymously assist who are being bullied or as a parent concerned about your child's school safety. We want to make sure our students feel safe. This information is reviewed regularly during school hours. If you have added your contact information, please allow at least 24 hours for someone from the school to reply. If you responded anonymously, please add enough information for school staff to begin an investigation. If this is an emergency or needs immediate attention please contact your student's Principal or counselor directly.

Today's Date *

YYYY

Your name (optional)

Your telephone number and/or email address (optional)

Are you a: *

Student

Parent

Staff Member

Other:

Name of person(s) being bullied: *

Student's Grade Level and Teacher *

Name of alleged offender. *

Alleged Offender's Grade Level and Teacher (if known)

Is the alleged offender older or younger than the person being bullied? *

Same grade

In lower grade.

In upper grade.

Date of the incident *

YYYY

Name of any other person that could have seen the incident and could provide more information. *

Where did the incident occur (check all that apply) *

Classroom

Hallway

Bathroom

Gym

Cafeteria

School sponsored event: athletic event, dance, etc.

On the way to or from school

Bus

Other:

Required

Check the statement that BEST describes what happened:

Hitting, kicking, shoving, spitting, hair pulling, or throwing something

Getting another student to hit or harm the student(s)

Teasing, name-calling, making critical statements (racial comments, sexual orientation), or threatening a person or other means of communicating threats

Demeaning the victim and/or making jokes about the victim

Making rude and/or threatening gestures

Excluding or rejecting the student

Intimidating (bullying), extorting or exploiting

Spreading harmful rumors or gossip

Electronic Communication (please also select which type from below)

Texting

Social Networks: Facebook, Twitter, MySpace

Webpostings

Blogs

Other:

Clear selection

Does this meet the definition of bullying? Definition: Intentionally aggressive behavior, repeated over time and involves an imbalance of power. If so, provide more information. *

Yes

Other:

To your knowledge, has this been reported before? *

Yes

Unsure

If you answered "YES" to answer above, did someone respond within 24 hours? If not, did you follow up with a phone call to the administration of the school for assistance? If so, what was the outcome?

Is there any additional information that you would like to provide? *

Submit

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