Bullying and Harrassment Incident Report Form

Wakefield Public Schools Bullying/Harassment Incident Report Form

Bullying is defined as the repeated use by one or more students of a written, verbal, or electronic expression, or physical act or gesture or any combination directed at a target that causes the following:

Physical or emotional harm to the target, damage to the target's property, places the target in reasonable fear of harm to him or herself, creates a hostile environment at school for the target, infringes on the rights of the target at school, substantially disrupts the education process or orderly operation of a school.

Directions: By law, all school employees are required to report alleged acts of bullying. Please complete this form. If you are a student, parent, or volunteer and wish to remain anonymous please omit signature and name. All reports of bullying will be investigated and parties will be informed.

(Note: Reports may be made anonymously, but no displinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.)

Date of Alleged Incident * +

Name of targeted individual

School *

Grade *

Name of Alleged Offender

Grade of the Alleged Offender *

Where did the incident happen? *

Please check each statement that best describes what was observered *

Please describe the incident

Email Address: *

Name/contact information of person reporting incident

What actions, if any, were taken at time of incident? *

Police Notification

Parent Notification

What Actions, if any, were taken at time of incident? *

Phone

Email

Conference

Mail

I agree that all of the information on this form is accurate to the best of my knowledge.

Date * +

Dolbeare	Doyle	Greenwood	Walton	Woodville
GMS	WHS

PRE-K	K	01	02	03	04	05
06	07	08	09	10	11	12

PRE-K	K	01	02	03	04	05
06	07	08	09	10	11	12

School Property	Off Campus
School Sponsored Event	School Bus
Other Other