SMS Student Incident Report Form

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This form is to report an alleged incident of inappropriate behavior, bullying, or harassment that occurred in any of the following locations; on school property, at a school-sponsored activity, or on a school bus. This form is also used to anonymously report alleged safety issues that may arise on school property, at a school-sponsored activity, or on a school bus. Please complete this form - when submitted, it will be forwarded to the building administration.

You also have the option to report any incident to the Stonington School District Title IX Coordinator, Mrs. Allison VanEtten. Email Avanetten@stoningtonschools.org or phone (860) 572-0506.

You are also encouraged to report this to your building principal, guidance counselor, teacher, or any trusted adult in your school building.

PLEASE NOTE:
These reports are received during school hours only. This form is not to be used to replace appropriate notifications of emergencies and/or reports for those requiring immediate mental health intervention. For emergencies related to immediate safety, including harm to self or others, please contact 911, and utilize 211 for mental health resources and supports. You may also contact the Stonington Police Department at 860-599-4411.

Your Name:

OPTIONAL: You do not have to give your name when reporting an incident, however, you must be aware that without your name, school personnel will not have a way to contact you or talk with you in confidence. Your privacy will be respected. False reports and/or accusations will be dealt with harshly.

I am... *

Choose one

Student

Staff Member

Parent/Caregiver

Person being bullied

Friend

Other:

I have reported this incident to an adult. *

Yes

If yes, whom did you report it to?

Name of person being bullied or victimized: *

Where did this happen? *

Classroom

Cafeteria

Hallway

Playground/Outdoor areas

Bathroom

Bus

Electronic Device

Other:

Date(s) and Time(s) of incident *

Name of the person(s) who is bullying, harrassing, or causing the safety issue: *

Type of behavior or safety issue: *

Choose the best description

Name Calling

Intentional Exclusion

Property Damage

Teasing in a hurtful way

Threatening

Physical Altercation

Cyber-bullying

Suspicious Social Media Posts

Harrassment

Sexual Harrassment

Sexting

Possession of an item that is prohibited in school. (weapons, drugs, vaping material)

Other:

What exactly happened? Please provide a detailed account of the incident to include time, date, location. *

Is there any other person who may have witnessed this incident? Was there any other person who was in the area when the incident took place? *

Was this the first time this incident happened or the first time you witnessed an incident between the parties involved? Are you aware of any prior relationship between the people involved? *

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