Strafford R-VI School District High School Bullying Prevention & Intervention Reporting Form
This form should be used to report a possible incident of bullying. Any student, parent, or staff member can report bullying or harassment by completing this form.
YOUR NAME: *
Your answer
HOW CAN YOU BE CONTACTED? *
Your answer
DID YOU WITNESS THE INCIDENT? *
VICTIM'S NAME: *
If you are the victim simply type your name again. If you are a reporter and not the victim, type the name of the victim.
Your answer
CHECK WHETHER YOU ARE A: *
Required
NAME(S) OF STUDENT(S) ACCUSED OF BULLYING: *
Your answer
WHEN DID THIS INCIDENT OCCUR? (DATE) *
If multiple incidences have occurred on a different day or time, please complete a new form for each incident.
MM
/
DD
/
YYYY
WHEN DID THIS INCIDENT OCCUR? (TIME) approximate *
If multiple incidences have occurred on a different day or time, please complete a new form for each incident.
Time
:
WHERE DID THE INCIDENT OCCUR? *
Required
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words) *
Your answer
LIST ANY WITNESSES TO THIS INCIDENT BELOW: *
Your answer
Is there any other information you believe is relevant for the district to know when investigating this incident? *
Your answer
TYPE YOUR FULL NAME BELOW AS YOUR SIGNATURE: *
Your answer
Submit
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