Overlook Middle School

Bullying Prevention and Intervention Report Form

Appendix E

ASHBURNHAM-WESTMINSTER REGIONAL SCHOOL DISTRICT

BULLYING PREVENTION AND INTERVENTION REPORTING FORM

SCHOOL :_______________________________ DATE:_________________________

Name of reporter: _____________________             Role_________________________ 

(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.)

Please provide your contact information/telephone number: ______________________

Incident Information:

Date(s) of Incident: ________________________________________________________

Time When Incident(s) Occurred:_____________________________________________

Location of Incident(s) (be specific):___________________________________________

Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used.)

________________________________________________________________________________________________________________________________

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

Name: ______________________________   ___Student  ___ Staff ___Other 

Name: ______________________________   ___Student ___ Staff ___Other 

Name: ______________________________    ___Student ___ Staff ___Other

Signature of person filing this report:____________________ Date: ______________

Administrator receiving report: ________________Position:____________________

Signature of administrator receiving this report:___________ Date: ____________