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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