5131.911 Form

REPORT OF SUSPECTED BULLYING BEHAVIORS

Name of Person Completing Report: _______________________________________________

Date: __________________

Target(s) of Behaviors: _____________________________________________________________________________

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, the approximate dates and the location:

_______________________________________________________________________________________________

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

For Staff Use Only:

_______________________________________________________________________________________________

Has reporter requested anonymity? Y N

Does the school have parent/guardian consent to disclose the student’s name in connection with the investigation? Y N

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 Notified:______________

Parents’ Names: _____________________________ Date Notified: ______________

If Bullying Verified, Has Invitation to Meeting Been Sent to Parents of Students?

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, witness statements, and notification to parents of students involved if bullying is verified, Invitations to Parent Meetings, Records of Parent Meetings)

SEYMOUR PUBLIC SCHOOLS

REPORT OF BULLYING FORM/INVESTIGATION SUMMARY

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: ______________________________________________

_________________________________________________________________________

For Staff Use Only:

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: ______________

If Bullying Verified, Have Invitation to Meetings Been Sent to Parents of Students Involved?

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, witness statements, and notification to parents of students involved if bullying is verified, invitations to parent meetings, records of parent meetings).

Seymour 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 Seymour Public Schools may need to disclose the name of your child and/or other information in connection this investigation which may otherwise disclose your child’s identity.

(Please check one):

_______ I hereby give permission for the Seymour Public Schools to disclose my child’s name, along with any other information necessary to permit the district to adequately and appropriately investigate such report, to third parties contacted by the district as part of its investigation.

______ I do NOT give permission for the Seymour Public Schools to disclose my child’s name, along with any other information necessary to permit the district to adequately and appropriately investigate such report, to third parties contacted by the district as part of its investigation.

_________________________________________

Signature of Parent/Guardian Date

_________________________________________

Name (Please print)