DMS Student Incident Report Form
This form is to report inappropriate behavior, bullying, or harassment that occurs at Deans Mill School, at a school activity, or on the school bus. This form is also used to report any safety or health/wellbeing issues at DMS, at a school activity, or on the school bus. Please complete this form - when submitted, it will be forwarded to Ms. McCurdy & Mr. Bousquet.
You also have the option to report any incident to the Stonington School District Title IX Coordinator, Mrs. Allison VanEtten. Email
Avanetten@stoningtonschools.org
or phone (860) 572-0506.
You are also encouraged to report this to Ms. McCurdy, Mr. Bousquet, Mrs. Robenhymer, Ms. Moniz, or any trusted adult at DMS!
PLEASE NOTE:
These reports are received during school hours only. This form is not to be used to replace appropriate notifications of emergencies and/or reports for those requiring immediate mental health intervention. For emergencies related to immediate safety, including harm to self or others, please contact 911, and utilize 211 for mental health resources and supports. You may also contact the Stonington Police Department at 860-599-4411.
* Required
Email address
*
Your email
Your Name:
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.
Your answer
I am...
*
Choose one
Student
Staff Member
Parent/Caregiver
Person being bullied
Friend
Other:
I have reported this incident to an adult.
*
Yes
No
If yes, whom did you report it to?
Your answer
Name of person being bullied or victimized:
*
Your answer
Where did this happen?
*
Classroom
Cafeteria
Hallway
Playground/Outdoor areas
Bathroom
Bus
Electronic Device
Other:
Option 1
Clear selection
Date(s) and Time(s) of incident
*
Your answer
Name of the person(s) who is bullying, harrassing, or causing the safety issue:
*
Your answer
Type of behavior or safety issue:
*
Choose the best description
Name Calling
Intentional Exclusion
Property Damage
Teasing in a hurtful way
Threatening
Physical Altercation
Cyber-bullying
Suspicious Social Media Posts
Harrassment
Sexual Harrassment
Sexting
Possession of an item that is prohibited in school. (weapons, drugs, vaping material)
Other:
What exactly happened? Please provide a detailed summary of the incident to include time, date, location.
*
Your answer
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?
*
Your answer
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?
*
Your answer
A copy of your responses will be emailed to the address you provided.
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