5131.911 Form 1
Enfield Public Schools Report of Bullying / Teen Dating Violence Form / Investigation Summary
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 _____
Remedial Action ( s ) Taken :
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