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BULLYING PREVENTION AND INTERVENTION PLAN
INCIDENT REPORTING FORM

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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.)

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Check whether you are the:

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Check whether you are a:

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If student, state your school:

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Grade:

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If Staff member, state your school or work site:

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Information about the Incident:
  • Name of Target (of behavior):

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  • Name of Aggressor (s) (Person who engaged in the behavior):

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  • Date(s) of Incident(s):

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  • Time When Incident(s) Occurred:

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  • Location of Incident(s) (Be as specific as possible):

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Witnesses (List people who saw the incident or have information about it):

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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.

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Signature of Person Filing this Report: 
(Note: Reports may be filed anonymously.)

APPENDIX A

Definition of Terms

Aggressor is a student or a member of a school staff who engages in bullying, cyberbullying, or retaliation towards a student.

 

Bullying is the repeated use by one or more students or a member of a school staff including, but not limited to, an educator, administrator, school nurse, cafeteria worker, custodian, bus driver, athletic coach, advisor to an extracurricular activity or paraprofessional of a written, verbal or electronic expression or a physical act or gesture or any combination thereof, directed at a target that: (i) causes physical or emotional harm to the target or damage to the target’s property; (ii) places the target in reasonable fear of harm to himself/herself or of damage to his/her property; (iii) creates a hostile environment at school for the target; (iv) infringes on the rights of the target at school; or (v) materially and substantially disrupts the education process or the orderly operation of a school. Bullying includes cyberbullying (M.G. L. c. 71, 370).

 

Cyberbullying is bullying through the use of technology or any electronic devices such as telephones, cell phones, computers, and the Internet. It includes, but is not limited to, email, instant messages, text messages, and Internet postings. (M.G.L. c. 71, 370)

 

Hostile environment is a situation in which bullying causes the school environment to be permeated with intimidation, ridicule, or insult that is sufficiently severe or pervasive to alter the conditions of the student’s education. (M.G.L. c. 71, 370)

 

Target is a student against whom bullying, cyberbullying, or retaliation is directed. (M.G.L. c. 71, 370)

 

Retaliation is any form of intimidation, reprisal, or harassment directed against a student who reports bullying, provides information during an investigation of bullying, or witnesses or has reliable information about bullying. (M.G.L. c. 71, 370)
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