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I a e, t <br /> Appendix A Mashpee Public Schools <br /> Bullying Prevention and Intervention Incident Reporting Form <br /> Part I — Informa` iof n <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 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 number: <br /> 4. If student, state school: Grade: <br /> 5. If staff member,state your school or work 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) 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 what each <br /> person did and said, including specific words used). Please use additional space on back if necessary. <br /> FOR ADMINISTRATIVE USE ONLY <br /> 9. Signature of Person Filing this Report: Date: <br /> (Note: Reports may be fled anonymously.) <br /> 10: Form Given to: Position: Date: <br /> Signature: Date Received: <br /> 8 <br />