21-22 AWRSD Bullying Report
* Reports may be made anonymously, however no disciplinary action will be taken against the alleged aggressor solely on the basis of an anonymous report.

The MA DESE definition of Bullying:
The repeated use by one or more students [aggressor(s)] of a written, verbal or electronic expression or a physical act or gesture or any combination thereof, directed at a target that: (i) causes physical or emotional harm to the target or damage to the target's property; (ii) places the target in reasonable fear of harm to him/herself or of damage to his/her property; (iii) creates a hostile environment at school for the target; (iv) infringes on the rights of the target at school; or (v) materially and substantially disrupts the education process or the orderly operation of a school. For the purposes of requirements related to this law, bullying shall include cyber-bullying. https://www.doe.mass.edu/sfs/bullying/#8
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date of report *
MM
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DD
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YYYY
date of incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Location of Incident *
Reporter's Name
Reporter's Role (teacher, student, parent etc...) *
Contact Information of Reporter
Aggresor's Name *
Target's Name
Witness(s) ~ If applicable
Type of Bullying *
Brief Explanation of Incident *
Did physical injury result from the incident? *
If medical attention was required please describe:
Please provide additional information to aid in the investigation.  
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