Bullying/Retaliation Incident Report Form - Hanover Public Schools - Massachusetts

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Hanover Public Schools
Bullying /Retaliation Incident Report
 Cedar Elementary
 Middle School
 Sylvester Elementary
 High School
 Center Elementary
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
Parent
Other (specify)
4. Your contact information/telephone number:
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.
Office Use Only:
Received by:
Date:
X2 Input by:
Date:
Hanover Public Schools
Bullying /Retaliation Incident Report
 Cedar Elementary
 Middle School
 Sylvester Elementary
 High School
 Center Elementary
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
Parent
Other (specify)
4. Your contact information/telephone number:
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.
Office Use Only:
Received by:
Date:
X2 Input by:
Date:

Download Bullying/Retaliation Incident Report Form - Hanover Public Schools - Massachusetts

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