Incident Report Form (Fillable)

Clear Form


                                              Colchester Public Schools
                                       Incident Report: Suspected Bullying Behavior

  The purpose of this form is to document initial reports of suspected bullying behavior, or reports associated with a
  suspected bullying investigation. This form may be completed by students, parents, or employees, or by a School Climate
  Specialists assisting a student to make a report. With the exception of school employees, individuals who complete and
  submit this form may remain anonymous. Colchester Public Schools will protect reporters or individuals who assist in the
  investigation of an act of bullying from discrimination and retaliation.

                               Submit this form to the mailbox of the School Climate Specialist


  Today’s Date:
  Your name (required only for school employees):
  Your phone # and/or email (optional):
  Name of the Targeted Student:
  Grade of Targeted Student:
  Name of Student(s) Displaying Suspected Bullying Behavior:
  Grade of Student(s) Displaying Suspected Bullying Behavior:

  How did you become aware of this incident?
         It happened to me.                                                 I saw it happen.
         I was told by another individual not directly involved.            I was told by the student it happened to.
         Other:

  Is the Targeted Student willing to talk to someone in the school?

  Date, time, and location of incident – when and where did this occur?

  Were there any adults present?                 No             Yes, their name(s):

  Were there other students present?             No             Yes, their name(s):

  Describe, in detail, what happened.
  (please use the back of this form if you need more space)




Revised 4.26.21
  This/these incidents have already been reported to a school employee?    Yes               No         I don't know
  If yes, to whom and when?

        I have seen the suspected bully being mean-spirited to others.

        I have seen the targeted student being targeted by others.

  (For students/parents only) Were these events reported to any school employee?       Yes         No         I don't know
  If yes, please identify to whom, when, and what was reported.



  (For employees only) Describe actions you took to address the issue:




  Name of School Climate Specialist Receiving Report                                                         Date




                                                                                                  Report ____ of ____

                                                                                   Investigation ID Number_______
                                                                                                        (YY/SS/#)
Revised 4.26.21
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