BULLYING PREVENTION AND INTERVENTION INCIDENT REPORTING FORM I. REPORT 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 3. Check whether you are a:
Reporter (not the target)
Student
Staff member (specify role)_________________________
Parent
Administrator
Other (specify) ___________________
Your contact information/telephone number: __________________________________________________ 4. If student, state your school: ___________________________________________ Grade: _____________ 5. If staff member, state your school or work site: _______________________________________________ 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.
9. Signature of Person Filing this Report: __________________________________ Date: ______________ (Note: Reports may be filed anonymously.) 10: Form Given to: __________________________ Position: ______________________ Date: __________ Signature: ___________________________________________________ Date Received: _______________
II. INVESTIGATION 1. Investigator(s):________________________________________ Position(s):________________________ 2. Interviews: □ Interviewed aggressor Name: ________________________________ Date: ___________________ □ Interviewed target Name: ___________________________________ Date: ___________________ □ Interviewed witnesses Name: ________________________________ Date: ___________________ Name: _____________________________________________________ Date: ___________________ 3. Any prior documented Incidents by the aggressor? □ Yes □ No If yes, have incidents involved target or target group previously?
□ Yes □ No
Any previous incidents with findings of BULLYING, RETALIATION □ Yes □ No Summary of Investigation:
(Please use additional paper and attach to this document as needed)
III. CONCLUSIONS FROM THE INVESTIGATION 1. Finding of bullying or retaliation: □ YES
□ NO
□ Bullying
□ Incident documented as _______________________________
2. Contacts: □ Target’s parent/guardian Date:___________ □ Aggressor’s parent/guardian Date: _________________ □ District Equity Coordinator (DEC) Date: ___________ □ Law Enforcement Date: __________________ 3. Action Taken: □ Loss of Privileges □ Detention □ STEP referral □ Suspension □ Community Service □ Education □ Other ________________________________ 4. Describe Safety Planning: _________________________________________________________________ Follow-up with Target: scheduled for __________________ Initial and date when completed: ___________ Follow-up with Aggressor: scheduled for ________________ Initial and date when completed: __________ Report forwarded to Principal: Date__________ Report forwarded to Superintendent: Date___________ (If principal was not the investigator) Signature and Title: _________________________________________________ Date: _________________
... limited to, any transfer or signs, signals,. writing, images, sounds, data or intelligence of any nature transmitted in whole or in part by a. wire, radio, electromagnetic, photo electronic or photo optical system, including, but not limited. to,
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... Education Programs (IEPs). This will include a particular focus on the needs of students with autism or students whose disability affects. social skills development. Additional areas identified by the school or district for professional developme
Georgia Chute Richard Galante ... ii | P a g e. Mission Statement. The mission of North Andover Public Schools is to cultivate a respectful community of engaged.
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The Olweus Bullying Prevention ProgramâFirst developed in Norway after a number of bullying victims .... article in the Journal of the American Medical.
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Submission of a good faith complaint. or report of bullying or harassment will not affect the complainant or reporter's future employment, grades,. learning, or working environment. A complainant that falsely accuses someone will be subject to. disci
investigate this matter if as much information as possible is provided. Submission of a good faith complaint. or report of bullying or harassment will not affect the complainant or reporter's future employment, grades,. learning, or working environme
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Page 1 of 3. 1. Focus on the whole school environment. The OBPP is a comprehensive, school-wide program that involves the entire school community in the form. of school-wide interventions, classroom activities, and individual interventions. To reduce
and using each idea to stimulate the generation of the next one ... except after Gâ rule, or possibly the â3 before 2 except after 10â .... gage in meaningful writing were plentiful, as children not only ..... move to later stages of instructio
Jan 1, 2014 - Kindergarten students will each make quilt squares depicting how they ... The quilt squares will be assembled to form a quilt-like pattern for all ...
IJRIT International Journal of Research in Information Technology, Volume 2, Issue 4, April 2014, Pg: 365- 373 ..... Packet passport uses a light weight message authentication code (MAC) such as hash-based message ... IP Spoofingâ, International Jo
170 KAPPA DELTA PI RECORD ⢠SUMMER 2006. Put a halt to ... The American Medical Association (AMA) claimed that half of ... be vigilant for signs that their young patients might be victims .... Provide consistent application of nonpunitive,.
harm, repeatedly demeaning speech and efforts to push someone out of a group or be ignored. Bullying is active, and is done with the ... Examples of Cyberbullying include mean text messages or emails, rumors sent by email or posted on social networki
123. Page 3 of 16. Comparing cyberbullying and school bullying among.pdf. Comparing cyberbullying and school bullying among.pdf. Open. Extract. Open with.