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: ___

II. INVESTIGATION
  1. Investigator(s): Position(s):
  2. Interviews:
□ Interviewed aggressor Name: Date:
□ Interviewed target Name: Date:
□ Interviewed witnesses Name: Date:
Name: Date:
      1. Any prior documented Incidents by the aggressor? □ Yes □ No
If yes, have incidents involved target or target group previously? □ Yes □ No
Any previous incidents with findings of BULLYING, RETALIATION □ Yes□ No
Summary of Investigation:










(Please use additional paper and attach to this document as needed)
III. CONCLUSIONS FROM THE INVESTIGATION
1. Finding of bullying or retaliation: □ YES □ NO
□ Bullying □ Incident documented as _
□ Retaliation □ Discipline referral only_

2. Contacts:
□ Target’s parent/guardian Date:_
□ Aggressor’s parent/guardian Date: _
□ Superintendent Date: _
□ Law Enforcement Date:

3. Action Taken:
□ Loss of Privileges □ Detention □ STEP referral □ Suspension
□ Community Service □ Education □ Other
  1. Describe Safety Planning: _

Follow-up with Target: scheduled for _ Initial and date when completed: _
Follow-up with Aggressor: scheduled for Initial and date when completed: _
Report forwarded to Principal: Date Report forwarded to Superintendent: Date_
(If principal was not the investigator)

Signature and Title: Date: _