ATHOL-ROYALSTON REGIONAL SCHOOL DISTRICT BULLYING PREVENTION AND INTERVENTION INCIDENT REPORTING FORM
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1. Name of Reporter/Person Filing the Report:
(Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.)
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2. Check whether you are the: *
3. Check whether you are a: *
Required
If Staff member, specify your role:
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4. If student, state your school: _ *
If student, what is your grade?
5. If staff member, state your school or work site:
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6. Information about the Incident (s):
Name of Target (of behavior): *
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Name of Aggressor (Person who engaged in the behavior): *
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Date(s) of Incident(s): *
MM
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DD
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YYYY
Time When Incident(s) Occurred: *
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Location of Incident(s) (Be as specific as possible): *
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7. Witnesses (List people who saw the incident or have information about it):
Name:
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Name:
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Name:
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8. Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used). *
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If the student is from another school /district...have you contacted the principal?
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9. Signature of Person Filing this Report: Sign or type your name.
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Date *
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YYYY
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