Form 1 Harassment, Intimidation, and Bullying Form - Greenwich-Stow Creek Township Partnership Schools

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Greenwich-Stow Creek Township Partnership Schools
Harassment, Intimidation, and Bullying Form
FORM 1
(To Be Completed By The Individual Reporting The Incident)
Name and status of individual providing initial report:_____________________
(i.e., employee, volunteer, student, parent, community member, etc.)
Check box if you wish to remain anonymous:
Date of alleged incident:____________________
Name(s) of alleged victim(s):
Name(s) of alleged offender(s):
_______________________________
______________________________
_______________________________
______________________________
Description of the alleged incident(s). Include any gestures, any relevant
written/verbal/physical act(s) as well as any electronic communications and identity
what, if any, actual or perceived characteristics were or may have been a motivating
factor in the alleged incident. If necessary, please use a separate page and attach it to this
form:
Greenwich-Stow Creek Township Partnership Schools
Harassment, Intimidation, and Bullying Form
FORM 1
(To Be Completed By The Individual Reporting The Incident)
Name and status of individual providing initial report:_____________________
(i.e., employee, volunteer, student, parent, community member, etc.)
Check box if you wish to remain anonymous:
Date of alleged incident:____________________
Name(s) of alleged victim(s):
Name(s) of alleged offender(s):
_______________________________
______________________________
_______________________________
______________________________
Description of the alleged incident(s). Include any gestures, any relevant
written/verbal/physical act(s) as well as any electronic communications and identity
what, if any, actual or perceived characteristics were or may have been a motivating
factor in the alleged incident. If necessary, please use a separate page and attach it to this
form:
Greenwich-Stow Creek Township Partnership Schools
Harassment, Intimidation, and Bullying Form
Indicate how you learned about the Alleged Incident:
Witness Alleged Incident
Informed by Alleged Victim
Informed by Other Person (If so, identify if student, parents, employee, or
volunteer): __________________________________________________
___________________________________________________________
Identify what harm you believe was or may have been caused by the alleged incident.
Check all that may apply:
Substantial disruption or interference with orderly operation of the school;
Substantial disruption or interference with rights of others;
Physical or emotional harm;
Insulting or demeaning;
Creates a hostile educational environment;
Interferes with student’s education;
Other (Please elaborate): ______________________________
List anyone who you know or have reason to believe may have relevant knowledge of the
alleged incident(s) (i.e., any eye witnesses or other persons with knowledge of what is
alleged to have occurred) and please indicate if the individual(s) is/are a student, parent,
staff member of other:
Name of person who received your initial verbal report (if any): ____________________
Date of your verbal report (if any): ___________________________________________
Person to whom you provided this written report: ________________________________
Signature:______________________________________________ Date:___________
(if anonymous, please place an “X” on the signature line)

Download Form 1 Harassment, Intimidation, and Bullying Form - Greenwich-Stow Creek Township Partnership Schools

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