Hamden Public Schools District Policies

5131.911 - Bullying (Sample Forms)

 

 [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)