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SAFE SCHOOL INITITATVE <br /> INCIDENT REPORTING/COMPLAINT FORM <br /> Mashpee Public School District <br /> 1. Name of Reporter/Complainant: <br /> 2. Check whether you are the: <br /> Target (of the behavior) : Reporter (not target of the behavior) :_ <br /> 3. Check whether you are:_Student _Staff member —Other(specify) <br /> 3a. Provide your contact information/ tel.# <br /> 4. If student, state your school: Grade: Homeroom: <br /> 5. If staff member, state your school or work site: <br /> 6. Information about the incident: <br /> Name of target (of behavior) : _student _staff _other <br /> Name of subject of report/complaint: _student _staff _other <br /> Date(s) of incident: <br /> Time when incident (s) occurred <br /> Incident location (be as specific as possible) <br /> 7. Witnesses: (List people who saw the incident or have relevant information about the <br /> incident) : <br /> Name: _student _staff _other <br /> Name: _student _staff _other <br /> 8. Describe the details of the incident (the names of persons involved, what occurred, <br /> and what each person did and said, including specific words used; use additional <br /> paper if necessary) : <br /> 9. Signature of reporter/complainant: Date: <br /> 10. Form provided to: Position: Date: <br /> Signature Date: <br /> 31 <br />