Report Bullying
This report MUST be completed to file a complaint relating to an incident of alleged bullying
(for purpose of this form, bullying encompasses bullying, harassment, and discrimination) and
turned in to the school Principal/designee of victim’s home school or the appropriate
area/district office.
Atención: Si usted. necesita una traducción al Español de este o cualquier otro documento, por favor póngase en contacto con Jess Bouchard. Teléfono: 413-743-7311, extensión 712.
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Your Name (last, first, middle)
(optional)
Your Contact Information
please provide telephone number or email address (optional)
Target Name (last, first, middle) *
Who has been bullied?
Aggressor Name/s (last, first, middle) *
Who was bullying? List all if more than one.
Site of incident. *
Please be specific. For example, if at school state room or area.
Date and approximate time of incident. *
MM
/
DD
/
YYYY
Time
:
Describe the incident. *
Use as much detail and specific names as possible.
List all witnesses to the incident. *
List evidence of bullying. *
things like letters, photos, etc. Provide copies to Jess Bouchard, jess.bouchard@bartcharter.org
Type your name as signature below: *
I agree that all of the information on this form is accurate and true to the best of my knowledge.
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