Bullying Policy and Reporting

Name of Reporter/Person Filing the Report:

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

(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.)

Are you the: REQUIRED Target of the behavior Reporter (not the Target) Please fill out this field.

Are you a: REQUIRED Student Staff Member Parent/Guardian Administrator Other Please fill out this field.

If Staff Member or Other, please specify your role: Please enter valid data.

If Student, state your school: Please enter valid data.

If Staff Member, state your school or work site: Please enter valid data.

Your contact information/telephone number: REQUIRED Please fill out this field. Please enter valid data.

Information about the incident:

Name of Target (of behavior): REQUIRED Please fill out this field. Please enter valid data.
Name of Aggressor (Person who engaged in behavior): REQUIRED Please fill out this field. Please enter valid data.
Date(s) of Incident(s): REQUIRED Please fill out this field. Please enter valid data.
Time When Incident(s) Occurred: REQUIRED Please fill out this field. Please enter valid data.
Location of Incident(s) (Be as specific as possible): REQUIRED Please fill out this field. Please enter valid data.

Witnesses (List of people who saw the incident or have information about it):

Name (Person 1): REQUIRED Please fill out this field. Please enter valid data.
Role (Person 1): REQUIRED Student Staff Other Please fill out this field.
Name (Person 2): Please enter valid data.
Role (Person 2): Student Staff Other
Name (Person 3): Please enter valid data.
Role (Person 3): Student Staff Other

Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used). REQUIRED Please fill out this field.

For Administrative Use Only:

Signature of Person Filing this Report: Please enter valid data.
(Note: Reports may be filed anonymously.)
Date: Please enter a date.
Form Given to: Please enter valid data.
Position: Please enter valid data.
Date: Please enter a date.
Signature: Please enter valid data.
Date Received: Please enter a date.

Saint Charles School

Woburn, MA

Bullying Policy and Reporting

Bullying Prevention and Intervention

Bullying Prevention and Intervention Incident Reporting Form