BULLYING PREVENTION AND INTERVENTION INCIDENT REPORTING FORM

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Name of Reporter/Person Filing the Report (Note: Reports may be made anonymously, but no disciplinary action will be taken against the alleged aggressor solely on the basis of an anonymous report.)

Check whether you are: *

Target of the behavior

Reporter (not the target)

Indicate if you are a:

Student

Staff member

Parent

Administrator

Other:

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Your contact information/telephone number:

If you are a student do you attend

Hildreth

Bromfield

Clear selection

Grade Level

Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used)

Name of Target (of behavior):

Name of Aggressor (Person who engaged in the behavior)

Date(s) of Incident(s)

Time When Incident(s) Occurred:

Location of Incident(s) (Be as specific as possible)

Witnesses (List people who saw the incident or have information about it):

Witness 1 Name (Indicate if Student, Staff or Other)

Witness 2 Name (Indicate if Student, Staff or Other)

Witness 3 Name (Indicate if Student, Staff or Other)

Submit

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