ATHOL-ROYALSTON REGIONAL SCHOOL DISTRICT BULLYING PREVENTION AND INTERVENTION INCIDENT REPORTING FORM
Sign in to Google to save your progress. Learn more
Email *
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.)
2.   Check whether you are the:   *
3.   Check whether you are a: *
Required
If Staff member, specify your role:
4.  If student, state your school: _ *
If student, what is your grade?
Clear selection
5.   If staff member, state your school or work site:
6.   Information about the Incident (s):  
Name of Target (of behavior): *
Name of Aggressor (Person who engaged in the behavior): *
Date(s) of Incident(s): *
MM
/
DD
/
YYYY
Time When Incident(s) Occurred: *
Location of Incident(s) (Be as specific as possible): *
7.   Witnesses (List people who saw the incident or have information about it):
Name:
Clear selection
Name:
Clear selection
Name:
Clear selection
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). *
If the student is from another  school /district...have you contacted the principal?
9.  Signature of Person Filing this Report:    Sign or type your name.
Date *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Athol-Royalston Regional School District. Report Abuse