Enfield Public Schools Report of Bullying / Teen Dating Violence Form / Investigation Summary
5131.911 Form 1
School Date
Location ( s )
Reporter Information :
Anonymous student report Staff Member report Parent / guardian report Student report
Name Name 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 _____ Teen Dating Violence Verified ? Yes _____ No _____
Revised 8 / 23 / 2024