BULLYING PREVENTION AND INTERVENTION INCIDENT REPORTING FORM

1.   Name of Reporter/Person Filing the Report:______________________________________________________

(Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the

 basis of an anonymous report.)

2.   Check whether you are the:          Target of the behavior                       Reporter (not the target)

3.   Check whether you are a:          Student                     Staff member (specify role) ________________________________

                                                       Parent                     Administrator             Other (specify) _______________________

Your contact information/telephone number:_________________________________________________________

4.   If student, state your school: _________________________________________________   Grade: _____________  

5.   If staff member, state your school or work site: ______________________________________________________

6.   Information about the Incident:                                                                

        Name of Target (of behavior): ___________________________________________________________________  

        Name of Aggressor (Person who engaged in the behavior): ____________________________________________

        Date(s) of Incident(s):  ___________________________________________________________________________

        Time When Incident(s) Occurred: _______________________________________________________________

        Location of Incident(s) (Be as specific as possible): ____________________________________________________

7.   Witnesses (List people who saw the incident or have information about it):

        Name: _________________________________________     • Student  • Staff  • Other ________________________

Name: _________________________________________     • Student  • Staff  • Other ________________________

Name: _________________________________________     • Student  • Staff  • Other ________________________

8.  Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used).  Please use additional space on back if necessary.

9.  Signature of Person Filing this Report: ___________________________________________ Date: ______________

        (Note: Reports may be filed anonymously.)

10:  Form Given to: __________________________________   Position: ______________________ Date: __________

        Signature: ______________________________________________________ Date Received: _______________

INVESTIGATION

1. Investigator(s):___________________________________________________        Position(s):________________________
2. Interviews:                                                          

□ Interviewed aggressor        Name: ___________________________________        Date: ___________________        

□ Interviewed target                   Name: ___________________________________        Date: ___________________

□ Interviewed witnesses         Name: ___________________________________        Date: ___________________

                                                Name: ___________________________________        Date: ___________________

3. Any prior documented Incidents by the aggressor?        □ Yes        □ No

If yes, have incidents involved target or target group previously?          □ Yes         □ No

Any previous incidents with findings of BULLYING, RETALIATION                □ Yes        □ No

Summary of Investigation:

 (Please use additional paper and attach to this document as needed)

CONCLUSIONS FROM THE INVESTIGATION

1.  Finding of bullying or retaliation:        

□ YES                                                         □ NO

           □ Bullying                                                   □ Incident documented as ___________________________

□ Retaliation                                                      □ Discipline referral only_____________________________                

2.  Contacts:

            □ Target’s parent/guardian    Date:______________        □ Aggressor’s parent/guardian    Date: _________________

 □ District Equity Coordinator (DEC)        Date: ______________   □ Law Enforcement     Date: ___________________

3.  Action Taken:

□ Loss of Privileges      □ Detention     □ STEP referral    □ Suspension        

□ Community Service    □ Education    □ Other ________________________________

4. Describe Safety/Intervention Planning:  _____________________________________________________________________________

Follow-up with Target:  scheduled for __________________________   Initial and date when completed: _________

Follow-up with Aggressor:  scheduled for _______________________  Initial and date when completed: _________

Report forwarded to Principal: Date__________________  Report forwarded to Superintendent:  Date_________________

(If principal was not the investigator)    

     Signature and Title: ___________________________________________________________   Date: _________________