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Colchester Public Schools
Challenging Behavior Report Form
Challenging Behavior Reporting Form
This form is not required by law or policy but serves as a model challenging behavior reporting form that local and
regional boards of education may adapt and adopt.
Instructions
This form is for students, parents or guardians of students enrolled in the school, and school employees to
report any alleged challenging behavioral incidents. Challenging behavior is behavior that negatively impacts school
climate or interferes, or is at risk with interfering, with the learning or safety of a student or the safety of a school
employee. This form should also be used to report alleged bullying incidents, meaning: unwanted and aggressive
behavior among children in grades kindergarten to twelve, inclusive, that involves a real or perceived power
imbalance.
Complete this form electronically, or in writing, or go to your school climate specialist (principal, vice principal, or
other certified administrator) who will assist you with completing this form. All completed reports require a
response from the school climate specialist, and every student, parent or guardian, and school employee who
completed this form will receive a copy of the “Response Process(es) Notification Form” describing the action
steps taken, within three (3) school business days after an assessment has been completed.
The school climate specialist will assess the facts of a challenging behavior incident and complete the "Response
Process(es) Notification Form” (located on page 5 of this document). A confirmation of receipt of the “challenging
behavior reporting form” will be provided to the individual who completed this form within three (3) school
business days, and the behavioral assessment will be finalized within a reasonable amount of time.
If this is an emergency, and you feel that you or someone else is in imminent danger, please call 911, or your
municipal police department.
Name: First __________________________ Last _______________________ or check here ☐ for any student
who would like to submit anonymously.
I am a: ☐ Student, ☐ Parent and/or Guardian or ☐ School Employee
Email:
Phone Number:
Contact me by: ☐ Phone ☐ Email
Was this previously reported to any school employee prior to this report? If yes, identify to whom, when, and what
was reported?
Where did the incident occur?
Check any boxes that apply.
On school property On a school bus
At a school-sponsored activity or off school On the way to/from school
property Outside of school
Electronic communication, internet, and Other
social media
Approximate date of incident (if known):
This form does not modify or eliminate any rights or obligations under state and federal laws, including, any constitutional and
civil rights protections, or any applicable policies and procedures or collective bargaining agreements. All students' private and
personal information will remain confidential throughout this process, subject to any wavier rights or disclosure responsibilities
as permitted or required by law.
Please note: when a student exhibits challenging behavior, our priority is to ensure the safety of the students and the school, and
to work with the student(s) to prevent the recurrence of such behavior, including making amends for any challenging behaviors
that occurred. Federal law protects the privacy of each student. Therefore, you cannot be provided with any specific information
concerning the student alleged to have engaged in the challenging behavior.
Form 1
(continued)
Please describe what happened?
Of the following statement(s) check any that may describe or include what happened:
Teasing, name-calling, intimidating, or Making intimidating, and/or threatening
threatening, in person or through electronic gestures or remarks
communication Getting another person to do any of the
Spreading rumors or gossip behaviors listed above
Hitting, kicking, shoving, spitting, hair Unwanted contact of a sexual nature (verbal,
pulling, or throwing something or other acts non-verbal, physical)
of physical aggression
Do you believe that the reported instance(s) of challenging behavior was in reference to a student’s perceived or
actual age, ancestry, color, learning disability, marital status, intellectual disability, national origin, physical
disability, mental disability, race, religious creed, sex, gender identity or expression, sexual orientation, and status as
a veteran? If so, why?
If known, provide the name(s) of any witness(es) of the alleged incident:
Date form submitted:
*For school climate specialist use only:
Date received by school climate specialist:
Signature of receipt by school climate specialist:
This form does not modify or eliminate any rights or obligations under state and federal laws, including, any constitutional and
civil rights protections, or any applicable policies and procedures or collective bargaining agreements. All students' private and
personal information will remain confidential throughout this process, subject to any wavier rights or disclosure responsibilities
as permitted or required by law.
Please note: when a student exhibits challenging behavior, our priority is to ensure the safety of the students and the school, and
to work with the student(s) to prevent the recurrence of such behavior, including making amends for any challenging behaviors
that occurred. Federal law protects the privacy of each student. Therefore, you cannot be provided with any specific information
concerning the student alleged to have engaged in the challenging behavior.