Report Bullying/Other Concerns

Please note that these reports are not read immediately after submission but are generally read within 24-hours on regular school days and within 48-hours on the weekend. If you or someone you know is in crisis or in danger, please do not leave a report. Instead, try:

Call the 24-hour, 7 days a week HOPELINE at (800) 784-2433
Send a "text to talk" to 844-670-5838.
Call 911

This will ensure that someone will be able to respond immediately to the emergency situation.

Your Name (Optional, but helpful):

Please understand, without providing your contact information it may be difficult to pursue this report and to inform you of the status of the situation. If you would like to receive an email update on the status of the situation that you have reported you will need to leave your contact information (email) in this section.

Answer Required

I am a*

Answer Required

Victim

Guardian/Family Member

Student Witness

Other:

Describe what happened: Include information on the bully, victim, and witnesses/bystanders; the more detail you provide the better.

Alleged Bully or Offender*

Answer Required

Alleged Victim*

Answer Required

Witness/Bystanders*

Answer Required

What statements best describe what has happened (Choose all that apply)*

Answer Required

Physical Contact

Teasing

Social Exclusion

Stalking/Intimidation

Cyber Bullying

Other:

What statements best describe why you believe the behavior is happening (Choose all that apply)*

Answer Required

Racial

Sexual Preference

Gender

Other:

Describe the Incident*

Answer Required

Location (Choose all that apply)*

Answer Required

Off School Property

In A Class

In Hallway

In The Lunchroom

On the way to/from School

On the internet or cellphone (Social Media)

Date and Time this happened

Date*

Answer Required

Time*

Answer Required

What sort of help would you like with this issue?*

Answer Required

Would you be receptive to a peer mediation program to solve the current issue?*

Answer Required

Yes

If yes, please list both student names:

Answer Required

Have you told anyone else about this incident? (Optional)

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Additional Information

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Riverside BrookfieldHigh School

Please fix the highlighted areas below before submitting.

Report Bullying/Other Concerns