WPS Bullying Incident Report Form
Wellesley Public Schools (WPS) expects that all members of the school community will treat each other in a civil manner and with respect for differences in accordance with the District’s core values. The WPS does not tolerate bullying or retaliation in school buildings, on school grounds, or at school-related activities. All staff members who witness or become aware of bullying or retaliation must inform the Principal immediately. This form may be used for reporting bullying or retaliation. The Principal or his/her designee will investigate all reports of bullying and retaliations, as defined in Massachusetts General Laws Chapter 17, and will take prompt action to end the conduct and restore the target’s sense of safety. For more information, please refer to the WPS Bullying Policy,
Prevention and Intervention Plan, available at all schools and on the WPS website: https://wellesleyps.org/wp-content/uploads/2016/03/Bullying-Policy-revised2014.pdf.

When reporting bullying incidents through this form, please also note the following:

• Your confidentiality and trust is very important. We will make every effort to respect your privacy. Please be aware, however, in certain circumstances involving safety or criminal action, we may not be able to guarantee complete anonymity.
• Anyone reporting an incident through this form should provide reliable contact information, so that we may contact you if there is a need for clarification or if additional questions or concerns arise. Also, if you want to receive a copy of your report, you will need to enter an email address in the Background Information section.

STOP! If this is an emergency situation, CALL 911 or the Wellesley Police Department at (781) 235-1212. Do not use this form to report events that present an immediate threat to health or safety.

If you have any questions about filing or completing a report, please contact:
- the school principal for student issues or
- the Human Resources Department for staff issues.
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Name
Please enter your name.
Email Address
Please enter your email address. (Email is required if you want a copy of your report.)
Phone Number
Please enter your 10 digit phone number.
You are the... (check all that applies) *
Required
Role *
Please indicate your role in the schools/community.
School *
Please indicate the school the incident is connected to.
Target(s) *
 Please list names(s) of target(s) of bullying incident.
Aggressor(s) *
Please list name(s) of person(s) who engaged in the behavior.
Date(s), time(s) and location(s) of Incident *
Please list dates, approximate times, and location(s) of incident.
Witness(es) *
Please list person(s) who saw the incident or have information about it, and indicate whether they are staff, student, or other.
Description *
Describe the details of the incident including names of people involved, what occurred, and what each person did and said including specific words used.)
Bullying Criteria (Please check yes or no for each statement below as it applies to this report) *
The repeated use by one or more students or by a member of a school staff including, but not limited to, an educator, administrator, school nurse, cafeteria worker, custodian, bus driver, athletic coach, advisor to an extracurricular activity or paraprofessional, of a written, verbal or electronic expression or a physical act or gesture or any combination thereof, directed at a victim that:
Yes
No
(a)Causes physical or emotional harm to the victim or damage to the victim’s property
(b)Places the victim in reasonable fear of harm to himself or of damage to his property
(c)Creates a hostile environment at school for the victim
(d)Infringes on the rights of the victim at school
(e)Materially and substantially disrupts the education process or the orderly operation of a school
Repeated *
Was the aggressors behavior repeated more than once?
Cyberbullying: *
Yes
No
Was the bullying through the use of technology or any electronic communication?
Was the bullying through the creation of a web page or blog in which the creator assumes the identity of another person?
Was the bullying through knowing impersonation of another person as the author of posted content or messages?
Was the bullying accomplished by distribution by electronic means of a communication to more than one person or the posting of material on an electronic medium that may be accessed by one or more persons?
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