Russell Byers Charter School
Bullying Complaint Form
Date of Incident: Time of Incident:
Location of Incident:
Name(s) of victim(s) Name of Student(s) bullying: Name(s) of witnesses/bystanders
Type of Bullying:
If 'Other', please describe:
Verbal
Physical
Result in injury? Reported to the Nurse? Reported to the Police?
Bullying Behaviors(please check all that apply)
Shoved/Pushed
Excluded
Staring/Leering
Hit/Kicked/Punched
Taunting/Ridiculing
Intimidation/Extortion
Threatened
Writing/Graffiti
Demeaning Comments
Stole/Damaged Property
Told Lies/False Rumors
Inappropriate Touching
Cyber Bullying Usage:
Text messages
Website Email Other:
Racial
Sexual
Religious Disability
Describe:
Reported to the school by:
Describe the incident:
Physical Evidence:
Notes Email Graffiti
Video/Audio
Website
Name:
SECTION I:
Signature: Date:
(check one and describe)