CASE #

Newton Public School District
Staff/Parent Reporting Form
Harassment, Intimidation, Bullying
Directions: The Newton Public School District is committed to providing a safe environment to all members of our community. Despite our best intentions, incidents between students do occur at times. If you wish to report a disturbing incident between two or more students, complete this form and return it to the Principal or Anti-Bullying Specialist at the school. Contact the school for additional information or assistance at any time. This form can be completed anonymously by omitting signature and name.
Every reported act of HIB will be investigated. Parents of aggressors and targets will be contacted in cases of confirmed HIB.
Date of Alleged Incident:
Name(s) of Alleged Victims / Name(s) of Alleged Suspects
Check all actual or perceived characteristics that were or may have been motivational factors in the alleged bullying incident
Race / Color / Sexual Orientation / Gender
Ancestry / Religion / National Origin / Gender Identity
Mental or Physical or Sensory Disability
OTHER actual or perceived characteristic
Mark the statement(s) that best describes the behavior reported
teasing or name-calling / destruction of property / stalking another pupil
publicly humiliating a pupil / stealing or theft / defacing/destroying property
excluding or rejecting a pupil / extorting or exploiting a pupil / intimidating conduct
physical aggression or contact / insulting or demeaning comments
threatening comments, gestures, physical acts / getting another person to harm a pupil
spreading harmful rumors or gossip about a pupil
harassment, intimidation or bullying through electronic communications
other: please specify
Indicate how you learned that a student may have been the victim of harassment, intimidation or bullying
Witness Victim Other (Identify)
List any person who you know or have reason to believe may have relevant information and indicate if student, parent, staff member or other:
Describe nature of alleged harassment, intimidation or bullying. Include any gesture, any relevant written verbal or physical act[s], or any electronic communication (attach additional sheets if necessary):
Location of alleged HIB. Check and complete all that apply
School property / School-sponsored function (Identify)
School Bus / Off School Grounds (Describe):
Identify what harm you believe was or may have been caused by the alleged incident. Check all that apply:
Physical or emotional harm / Insulting or demeaning
Creates a hostile educational environment / Interferes with student’s education
Substantial disruption or interference with orderly operation of school or rights of others.
Describe in narrative form what harm you believe was caused to the victim and the basis for your belief
Please add any other pertinent information:
False Accusations: Any student who knowingly makes a false accusation of HIB orretaliation will be subject to disciplinary action including, but not limited to parent conferences,reprimand, detention, loss of privileges, and/or suspension. An educational component will bepart of the actions taken. If the false accusations have civil and/or criminal elements then furtheractions may be taken by appropriate law enforcement agencies.
Report Completed by:
Name: Date:

Parent Contact Information

Initial Notification

Victims Parents Contacted by:
Name:
Date: Time: / Mother
Father
Other:
Victims Parents Contacted by:
Name:
Date: Time: / Mother
Father
Other:
Victims Parents Contacted by:
Name:
Date: Time: / Mother
Father
Other:
Victims Parents Contacted by:
Name:
Date: Time: / Mother
Father
Other:
Suspects Parents Contacted by:
Name:
Date: Time: / Mother
Father
Other:
Suspects Parents Contacted by:
Name:
Date: Time: / Mother
Father
Other:
Suspects Parents Contacted by:
Name:
Date: Time: / Mother
Father
Other:
Suspects Parents Contacted by:
Name:
Date: Time: / Mother
Father
Other:

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