WVS Student Incident Report Form
This form is to report inappropriate behavior, bullying, or harassment that occurs at West Vine Street School, at a school activity, or on the school bus. This form is also used to report any safety issues at WVSS, at a school activity, or on the school bus. Please complete this form - when submitted, it will be forwarded to Mrs. Dawe & Ms. Irvine.
You also have the option to report any incident to the Stonington School District Title IX Coordinator, Mrs. Allison VanEtten. Email
or phone (860) 572-0506.
You are also encouraged to report this to Mrs. Dawe, Ms. Irvine, Mr. Andruchuve, Mrs. Bruno, or any trusted adult at WVS!
OPTIONAL: You do not have to give your name when reporting; however, you must be aware that without your name, school staff will not have a way to contact you or talk with you in confidence.
Person being bullied
I have reported this incident to an adult.
If yes, whom did you report it to?
Name of person being bullied or victimized:
Where did this happen?
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
Teasing in a hurtful way
Suspicious Social Media Posts
Possession of an item that is prohibited in school. (weapons, drugs, vaping material)
What exactly happened? Please provide a detailed summary 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 people involved? Are you aware of any prior relationship between the people involved?
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This form was created inside of Stonington Public Schools.