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Reading Public Schools
Bullying Prevention and Intervention Incident Reporting Form
Note: Reports made anonymously will be investigated but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.
Name of Reporting/Person filing the report: (not required)
First
Last
Your Phone Number
###
-
###
-
####
Your Email
Select whether you are the:
Target of the behavior
Reporter (not the target)
Select whether you are:
Student
Staff Member
Parent
Administrator
Other
If Student, please select your school:
Please select
Barrows
Birch Meadow
Coolidge
Eaton
High School
Killam
Parker
RISE
Wood End
Grade of Submitter:
Please select
K
1
2
3
4
5
6
7
8
9
10
11
12
If staff member, state your school or work site:
Please select
Administrative Offices
Barrows
Birch Meadow
Coolidge
Eaton
High School
Killam
Parker
RISE
Wood End
Information regarding the incident:
Name of target of behavior:
First
Last
School of Target:
Please select
Barrows
Birch Meadow
Coolidge
Eaton
High School
Killam
Parker
RISE
Wood End
Grade of Target
Please select
K
1
2
3
4
5
6
7
8
9
10
11
12
Name of Agressor (Person who engaged in the behavior):
First
Last
School of Agressor:
Please select
Barrows
Birch Meadow
Coolidge
Eaton
High School
Killam
Parker
RISE
Wood End
Grade of Agressor
Please select
K
1
2
3
4
5
6
7
8
9
10
11
12
Date and Time of Incident
MM
/
DD
/
YYYY
HH
:
MM
AM
PM
AM/PM
Location of Incident(s) (Please be as specific as Possible):
Is there an online/Internet component of this incident? Please Describe:
Witnesses
Please list people who saw the incident or have information about it.
Describe the details of the incident, including names of people involved, what occurred, and what each person did and said.
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