SMS Student Incident Report Form
This form is to report an alleged incident of inappropriate behavior, bullying, or harassment that occurred in any of the following locations; on school property, at a school-sponsored activity, or on a school bus. This form is also used to anonymously report alleged safety issues that may arise on school property, at a school-sponsored activity, or on a school bus. Please complete this form - when submitted, it will be forwarded to the building administration.
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 your building principal, guidance counselor, teacher, or any trusted adult in your school building.
OPTIONAL: You do not have to give your name when reporting an incident, however, you must be aware that without your name, school personnel will not have a way to contact you or talk with you in confidence. Your privacy will be respected. False reports and/or accusations will be dealt with harshly.
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 account 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 parties involved? Are you aware of any prior relationship between the people involved?
Never submit passwords through Google Forms.
This form was created inside of Stonington Public Schools.
Terms of Service