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Stanley Incident Report Form 2022-23
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* Indicates required question
Email
*
Your email
Are you the:
*
Target of Behavior
Reporter (not the target)
Required
Your first name
*
Your answer
Your last name
*
Your answer
Are you:
*
Choose
Student
Parent
Staff
Your phone number or email that we can contact you at? If you are a school employee, please type in your email and classroom extension
*
Your answer
Type of Possible Bullying Behavior
*
Physical (e.g. hitting, kicking, punching, spitting, tripping, pushing)
Verbal (e.g. taunting, name-calling, threatening words, notes or gestures, sexual comments, racial comments)
Relational (e.g. creating social isolation, spreading rumors, posting embarrassing images)
Required
Name of Person(s) who engaged in the above behavior:
*
Your answer
Name of Person(s) who was targeted by the above behavior:
*
Your answer
Is the alleged aggressor a Swampscott Public Schools staff member?
*
Yes
No
Grades of Students Involved (Check all)
*
K
1
2
3
4
5
6
7
8
9
10
11
12
Required
Date
*
MM
/
DD
/
YYYY
Approximate Time
*
Time
:
AM
PM
Location
*
On School Property
On the Bus
On the way to/from school
At a school-sponsored activity or event
Internet
Other:
Required
Briefly describe what happened (what occurred, specific words of what each person said and did)
*
Your answer
Witnesses: list all people who observed the incident or have information about the incident and their role (e.g. John Smith - Student)
*
Your answer
Check if aggression involved overt or suspected:
Racism
Sexism
Sexual Harassment
Sexual Assault
Homophobia
Transphobia
Ableism (targeted due to disability)
A copy of your responses will be emailed to the address you provided.
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