ENFIELD PUBLIC SCHOOLS
FORM A
REPORT OF SUSPECTED BULLYING BEHAVIORS OR TEEN DATING VIOLENCE
( School Employees Should File with the School Principal ) ( Parents and Students May File with the School Principal or Any Other School Employee )
Name of Person Completing Report : _______________________________________________ Date : __________________
Target ( s ) of Behaviors / Violence : _____________________________________________________________________________
Relationship of Reporter to Target ( self , parent , teacher , peer , etc .): _____________________________________________________________________________________ _______________________________________________________________________
Report Filed Against : ______________________________________________________________________
Date of Incident ( s ): _____________________________________________________________ Location ( s ):________________________________
Time : __________________
Describe the basis for your report . Include information about the incident , participants , background to the incident , and any attempts you have made to resolve the problem . Please note relevant dates , times and places . _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
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