INCIDENT REPORTING FORM
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BULLYING
For more information about bullying, please visit the following site: https://www.lowell.k12.ma.us/Page/714
Bullying is REPEATED use by one or more students of a written, verbal or electronic expression or a physical act or gesture or any combination thereof, directed at the victim that causes or places the victim in reasonable fear of harm to himself or of damage to his property, creates a hostile environment at school for the victim, infringes on the rights of the victim at school, or disrupts the education process.
Cyber-bullying is bullying through the use of technology or any electronic communication, which shall include but is not limited to electronic mail, internet communications, instant messaging, posting on social networking sites, or facsimile communications.
HARASSMENT
For more information about harassment, please visit the following site: https://www.lowell.k12.ma.us/Page/4400
Harassment is defined as any conduct of a verbal or physical nature that embarrasses, distresses, agitates, disturbs, causes fear, causes an apprehension of harm, harms or troubles a student on the basis of race, color, religion, ancestry, national origin, sex, socioeconomic status, homelessness, academic status, gender identity or expression, physical appearance, pregnant or parenting status, sexual orientation, gender identity, mental, physical, developmental or sensory disability or by association with a person who has or is perceived to have one or more of these characteristics.
DISCRIMINATION
For more information about discrimination, please visit the following site: https://www.lowell.k12.ma.us/Page/4400
Discrimination is the unfair treatment and/or a denial of one’s rights and privileges based on a person’s race, color, religion, ancestry, national origin, sex, marital status, socioeconomic status, homelessness, gender identity or expression, pregnancy or pregnancy related condition, parenting status, sexual orientation, disability (including but not limited to mental, physical, developmental or sensory), academic status, physical appearance or by association with a person who has or is perceived to have one or other of these characteristics.
RACISM
For more information about racism, please visit the following site: https://www.lowell.k12.ma.us/Page/4400
Racism is the belief and dominance of one race over all others, manifested in practices, beliefs, social relations, phenomena, institutions, structures, and systems. The reproduction and maintenance of a racial hierarchy and social structure that yield superiority, power, resources and privilege for some, and discrimination, exploitation and oppression for others.
Date of report: *
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Incident Type *
Incident based upon... *
Required
Name of person reporting the incident.
(Leave blank if you wish to remain anonymous).
Name:
If you are the person who suffered from the incident, then select Target. If you are reporting the incident, then select Reporter.
You are the: *
You are a(n): *
Your contact information/telephone number:
(Leave blank if you wish to remain anonymous).
Which school or work site should receive this report?
School or work site: *
If the target is a student, please state which grade the student is in.
Grade:
Name of the person(s) who suffered the aggression.
Target(s): *
Name of the person(s) who committed the aggression.
Aggressor(s): *
Date of incident: *
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YYYY
Time of incident: *
Time
:
Location of incident (be as specific as possible): *
List people who saw the incident - Bystanders.
Bystander (1):
What is the role/position of the Bystander?
Position (1):
Clear selection
Bystander (2):
Position (2):
Clear selection
Bystander (3):
Position (3):
Clear selection
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used).
What happened? *
Submit
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