[SAMPLE FORM A]
REPORT OF SUSPECTED BULLYING BEHAVIORS OR TEEN DATING VIOLENCE
(School Employees Should File with the School Principal)
(Parents and Students May File with the School Principal or Any Other School Employee)
Name of Person Completing Report: _______________________________________________
Date: __________________
Target(s) of Behaviors/Violence: _____________________________________________________________________________
Relationship of Reporter to Target (self, parent, teacher, peer, etc.): _________________________________________________________________________________________________________________________
Report Filed Against:_______________________________________________________________________
Date of Incident(s): _____________________________________________________________
Location(s):______________________________________ Time: __________________
Describe the basis for your report. Include information about the incident, participants, background to the incident, and any attempts you have made to resolve the problem. Please note relevant dates, times and places.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Indicate if there are witnesses who can provide more information regarding your report. If the witnesses are not school district staff or students, please provide contact information.
Name Address Telephone Number
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have there been previous incidents? (circle one) Yes No
If “yes”, please describe the behavior of concern, or the violence that occurred; include the approximate date(s) and the location(s):
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Were these incidents reported to school employees? (circle one) Yes No
If “Yes”, to whom was it reported and when?
______________________________________________________________________________
Was the report verbal or written? ______________________________________________________________________________
Proposed Solution:
Indicate your opinion on how this problem might be resolved in the school setting. Be as specific as possible.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I certify that the above information and events are accurately depicted to the best of my knowledge.
______________________________________________________________________________
Signature of Reporter Date Submitted Received By Date Received
[SAMPLE FORM B]
INTERNAL INVESTIGATION NOTES FOR REPORTS OF BULLYING BEHAVIORS
For Staff Use Only:
Has student reporter requested anonymity? Y N
Does the school have parent/guardian consent to disclose that a complaint as to this student has been filed in connection with the investigation? Y N
Administrative Investigation Notes (use separate sheet if necessary):
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Bullying Verified? Yes ___ No ____
Remedial Action(s) Taken:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(Attach bullying complaint and witness statements. If bullying is verified, attach notification to parents of students involved, invitation to parent meetings, and records of parent meetings).
[SAMPLE FORM C]
HAMDEN PUBLIC SCHOOLS
REPORT OF BULLYING FORM/INVESTIGATION SUMMARY
For Staff Use Only:_______________________________________________________
School _____________________________________ Date _______________________
Location(s) _____________________________________________________________
Reporter Information:
Anonymous student report _____
Staff Member report _____ Name ________________________
Parent/Guardian report_____ Name ________________________
Student report _____ Name ________________________
Student Reported as Committing Act: ______________________________________
Student Reported as Victim: ______________________________________________
Description of Alleged Act(s): _____________________________________________
______________________________________________________________________
Time and Place:________________________________________________________
Names of Potential Witnesses: ___________________________________________
______________________________________________________________________
Action of Reporter: ______________________________________________________
Administrative Investigation Notes (use separate sheet if necessary): _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Bullying Verified? Yes ___ No ____
Remedial Action(s) Taken:________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
If Bullying Verified, Has Notification Been Made to Parents of Students Involved?
Parents’ Names: _____________________________ Date Sent:______________
Parents’ Names: _____________________________ Date Sent:______________
Parents’ Names: _____________________________ Date Sent:______________
Parents’ Names: _____________________________ Date Sent: ______________
If Bullying Verified, Have Invitations to Meetings Been Sent to Parents of Students Involved?
Parents’ Names: _____________________________ Date Sent:______________
Parents’ Names: _____________________________ Date Sent:______________
Parents’ Names: _____________________________ Date Sent:______________
Parents’ Names: _____________________________ Date Sent: ______________
Date of Meetings:
_______________________________
_______________________________
If Bullying Verified, Has School Developed Student Safety Support/Intervention Plan?
Y N
(Attach bullying complaint and witness statements. If bullying is verified, attach: 1) notification to parents of students involved that includes a description of the school’s response to the acts of bullying, the results of the investigation, and via e-mail if e-mail addresses are known, a statement that the parents may refer to the plain language explanation of rights and remedies available under Conn. Gen. Stat. §§ 10-4a and 10-4b once such explanation has been provided to the Board by the Connecticut Social and Emotional Learning and School Climate Advisory Collaborative and published on the District’s website; 2) invitations to parent meetings; and 3) and records of parent meetings).
5/20/21
[SAMPLE FORM D]
[___________________________] Public Schools
Report of Bullying/Consent to Release Student Information
Date: ________________________________
Name of Student: ________________________________
School: ________________________________
To Parent/Guardian:
A report of bullying has been made on behalf of your child alleging that he/she has been the victim of bullying. In order to facilitate a prompt and thorough investigation of the report, the [__________________] Public Schools may wish to disclose the fact that this complaint has been filed in connection with investigation.
(Please check one):
_______ I hereby give permission for the [________________________] Public Schools to disclose the fact that a complaint concerning my child has been filed as part of its investigation of that complaint.
______ I do NOT give permission for the [________________________] Public Schools to disclose the fact that a complaint concerning my child has been filed as part of its investigation of that complaint.
_________________________________________
Signature of Parent/Guardian Date
_________________________________________
Name (Please print)
[SAMPLE FORM E]
[___________________________] Public Schools
Report of Teen Dating Violence/Consent to Release Student Information
Date: ________________________________
Name of Student: ________________________________
School: ________________________________
To Parent/Guardian:
A report of teen dating violence has been made on behalf of your child alleging that he/she has been the victim of teen dating violence. In order to facilitate a prompt and thorough review of the report, the [__________________] Public Schools may wish to disclose the fact that this complaint has been filed in connection with its review.
(Please check one):
_______ I hereby give permission for the [________________________] Public Schools to disclose the fact that a complaint concerning my child has been filed as part of its review of that complaint.
______ I do NOT give permission for the [________________________] Public Schools to disclose the fact that a complaint concerning my child has been filed as part of its review of that complaint.
_________________________________________
Signature of Parent/Guardian Date
_________________________________________
Name (Please print)