FORM C
ENFIELD PUBLIC SCHOOLS
REPORT OF BULLYING FORM/INVESTIGATION SUMMARY
For Staff Use Only:_______________________________________________________
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: ___________________________________________
______________________________________________________________________
Action of Reporter: ______________________________________________________
Administrative Investigation Notes (use separate sheet if necessary):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Bullying Verified? Yes ___
No ____
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