This report MUST be completed to file a complaint relating to an incident of alleged bullying
(for purpose of this form, bullying encompasses bullying, harassment, and discrimination) and
turned in to the school Principal/designee of victim’s home school or the appropriate
Atención: Si usted. necesita una traducción al Español de este o cualquier otro documento, por favor póngase en contacto con Erin Hattaway. Teléfono: 413-743-7311, extensión 712.
Your Name (last, first, middle)
Your Contact Information
please provide telephone number or email address (optional)
Target Name (last, first, middle)
Who has been bullied?
Aggressor Name/s (last, first, middle)
Who was bullying? List all if more than one.
Site of incident.
Please be specific. For example, if at school state room or area.
Date and approximate time of incident.
Describe the incident.
Use as much detail and specific names as possible.
List all witnesses to the incident.
List evidence of bullying.
things like letters, photos, etc. Provide copies to Erin Hattaway,
Type your name as signature below:
I agree that all of the information on this form is accurate and true to the best of my knowledge.
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This form was created inside of Berkshire Arts & Technology Charter Public School.