Bullying Prevention And Intervention Incident Reporting Form printable pdf download

BELMONT PUBLIC SCHOOLS

BULLYING PREVENTION AND INTERVENTION INCIDENT REPORTING FORM

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:

Target of the behavior

Reporter (not the target)

3. Check whether you are a:

Student

Staff member (specify role) ________________________________

Parent

Administrator

Other (specify) _______________________

Your contact information/telephone number:_________________________________________________________

4. If student, state your school: _________________________________________________ Grade: _____________

5. If staff member, state your school or work site: ______________________________________________________

6. Information about the Incident:

Name of Target (of behavior): ___________________________________________________________________

Name of Aggressor (Person who engaged in the behavior): ____________________________________________

Date(s) of Incident(s): ___________________________________________________________________________

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: _________________________________________

Student

Staff

Other ________________________

Name: _________________________________________

Student

Staff

Other ________________________

Name: _________________________________________

Student

Staff

Other ________________________

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). Please use additional space on back if necessary.

FOR ADMINISTRATIVE USE ONLY

9. Signature of Person Filing this Report: ___________________________________________ Date: ______________

(Note: Reports may be filed anonymously.)

10: Form Given to: __________________________________ Position: ______________________ Date: __________

Signature: ______________________________________________________ Date Received: _______________

Appendix A/Page 1/2

Bullying Prevention And Intervention Incident Reporting Form