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Appendix A Mashpee Public Schools <br /> Discrimination, Harassment, and Hate Crime Incident Reporting Form <br /> Part I—Information <br /> 1.Name of Reporter/Person Filing the Report: <br /> (Note: Reports may be made anonymously,but no disciplinary action will be taken against an alleged <br /> aggressor solely on the basis <br /> of an anonymous report.) <br /> 2. Check whether you are the: Target of the behavior Reporter(not the target) <br /> 3. Check whether you are a: Student: Staff Member (specify role) <br /> Parent: Administrator Other(specify) <br /> Your contact information/telephone <br /> number: <br /> 4. If student, state school: <br /> Grade: <br /> 5. If staff member, state your school or work <br /> site: <br /> 6. Information about the Incident: <br /> Name of Target: <br /> Name of Aggressor: <br /> Date(s) of Incident(s): <br /> Time When Incident(s) <br /> Occurred: <br /> Location of Incident(s): <br /> 7. Witnesses (List people who saw the incident or have information about it): <br /> Name: Student Staff Other <br /> Name: Student Staff Other <br /> Name: Student Staff Other <br /> 8. Describe the details of the incident(including names of people involved,what occurred, and <br /> what each person did and said, including specific words used). Please use additional space on back <br /> if necessary. <br /> FOR ADMINISTRATWE USE ONLY <br /> 9. Signature of Person Filing this Report: Date: <br /> (Note: Reports may be filed anonymously.) <br /> 10: Form Given to: Position: Date: <br /> 29 <br />