Overlook Middle School Bullying Reporting Form
Ashburnham-Westminster Regional School District: Bullying Prevention and Intervention Reporting Form
Date/Time
(Note: Reports may be made anonymously, but no disciplinary action will be taken against alleged aggressor solely on the basis of an anonymous report.)
Reporter
Your answer
Role (teacher, student, parent,)
Your answer
Contact Information of Reporter
Your answer
Date of Incident
MM
/
DD
/
YYYY
Time of Incident
Time
:
Location
Your answer
Aggressor
Your answer
Target
Your answer
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used. *
Your answer
Witnesses (if applicable)
Your answer
Submit
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