Bullying Prevention and Intervention Reporting Form
Name of Reporter/Person Filing the Report
Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.
Check whether you are the:
*
Target of the behavior
Reporter (not the target)
Check whether you are a:
*
Student
Staff Member
Parent
Administrator
Please select a school:
*
Curtis
Haynes
Loring
Nixon
Noyes
What grade are you in?
PK
K
1
2
3
4
5
6
7
8
What school do you work at?
Curtis
Haynes
Loring
Nixon
Noyes
What is your role at the school?
How can we contact you for follow up discussions?
Incident Information
Name of Target (of behavior):
Name of Aggressors (Persons who engaged in the behavior):
Date(s) of Incidents(s):
Time When Incident(s) Occurred:
Witnesses (List people who saw the incident or have information about it):
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used).
Affirmation
*
By checking this box, I affirm that the information I am entering is the accurate to the best of my knowledge.
Submit
Should be Empty: