FORM C
ENFIELD PUBLIC SCHOOLS
REPORT OF BULLYING FORM / INVESTIGATION SUMMARY For Staff Use Only : _______________________________________________________ School _____________________________________
Date _______________________ Location ( s ) _____________________________________________________________ Reporter Information :
o Anonymous student report ________________________________________ o Staff Member report _____ Name ___________________________________ o Parent / Guardian report _____ Name ________________________________ o 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 ): _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
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