Bullying/Incident Online Report Form - Old Colony Regional Vocational Technical High School

Old Colony RVTHS Bullying Prevention & Intervention Incident Reporting Form

Name of Reporter/Person Filing 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.)

Check whether you are the:*

Target of the behavior
Reporter (not the target)

Check whether you are a:

Student
Parent
Staff Member
Administrator
Other

If other, please specify:

If student, state your grade:

If staff, please state your title:

Your contact information/telephone number:

Information about the incident

Name of Target (of behavior):*

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

Date(s) of the Incident(s)*

Time when incident(s) occurred:*

Location of incident(s) (Be as specific as possible):*

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

Witness 1:

Witness 1 is:

Student
Staff
Other

Witness 2:

Witness 2 is:

Student
Staff
Other

Witness 3:

Witness 3 is:

Student
Staff
Other

Describe the details of the incident.

Include names of people invlved, what occured, and what each person did and said, including specific words used.*

Bullying Report Form

Old Colony RVTHS Bullying Prevention & Intervention Incident Reporting Form

Information about the incident

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

Describe the details of the incident.