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Name of Reporter/Person Filing the Report:    \n2. Check whether you are the:   Target of the behavior   Reporter (not the target) 3. Check whether you are a:   Student   Staff Member (position)  Parent    \nAdministrator   Other    \nYour contact information / Cell number & Email:  \n______________________________________________________________________________  \n4. Name of School (If student):    \n5. Grade:    \n6. If Staff member, State your school or work site:    \n7. Incident Information:  \nName of Target (of Behavior):   Name of Aggressor (Person who engaged in the behavior):    \nDate(s) of Incident(s):   Time when incident(s) occurred:    \nLocation of incident(s) (be as specific as possible):  \n__________________________________________________  \n8. Witness (List people who saw the incident or have information about it):  \nWitness Name:   Student Staff Other    \nWitness Name:   Student Staff Other    \nWitness Name:   Student Staff Other    \n“A Pathway for Every Student”  \n9. Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used) . Please use additional space on back if necessary  \n10. Signature of Person Filing this Report:   Date:    \nFOR ADMINISTRATIVE USE ONLY  \nForm Given to:   Date:    \nSignature:   Date received:    \nII INVESTIGATION  \n1. Investigator(s):   Position:    \n2. Interviews: (Please add witness statements/witness statement summary)  \nStatements:  \n● Interviewed Aggressor Name:   Date:   ●  \nInterviewed Target Name:   Date:   ●  \nInterviewed Witnesses Name:   Date:   ● Interviewed Witnesses Name:   Date:   3.  \nAny prior documented Incidents by the aggressor?   Yes   No  \nIf yes, have incidents involved a target or target group previously?   Yes   No Any  \nprevious incidents with findings of Bullying, Retaliation?   Yes   No  \nIf yes, Summary of Investigation:  \n(Please use additional paper and attach to this document as needed)  \n“A Pathway for Every Student”  \nIII CONCLUSIONS FROM THE INVESTIGATION  \n1. Finding of bullying or retaliation:  \nYes  \n__  \nNo  \n__  \n  Bullying Incident documented as    \n  Retaliation   Discipline referral only   Other    \nInvestigation Findings:  \n_______________________________________________________________________________________________  \n_______________________________________________________________________________________________  \n_______________________________________________________________________________________________  \n_______________________________________________________________________________________________  \n2. Contacts:  \nTarget’s Parent/guardian Pre‐Investigation Date:   Post Investigation Date:    \nAggressor’s parent/guardian Pre‐Investigation Date:   Post Investigation Date:   Student Services Director Date:    \nLaw Enforcement Date:    \nLaw Enforcement Date:    \nOther   Date:    \n3. Action Taken:  \n  Loss of Privileges   Detention   Suspension   Community Service   Restorative Justice Circle    \nEducation   Other    \nSummarize Action Taken:  \n____________________________________________________________________________________________  \n____________________________________________________________________________________________  \n____________________________________________________________________________________________  \n4. Describe Safety Planning:    \n5. Follow‐up with Target: Scheduled for    \n6. Initial and date when completed  / /   \n7. Follow‐up with Aggressor: Scheduled for    \n8. Initial and date when completed:  / /   \nReport forwarded to Principal: Date:    \nReport forwarded to Director of Student Services: Date:   (If principal was not  \nthe investigator)  \nPrincipal’s and / or Designee Signature and Title :  Date:    \nOn","cbCaim2eh08rAsRb","https://ap.wps.com/l/cbCaim2eh08rAsRb","pdf",524207,6,"English","# Incident Reporting\n## Reporter and Role Information\n## Incident Information\n## Witnesses and Incident Details\n## Signature\n# Administrative Use and Investigation\n## Investigator Details and Interviews\n## Prior Documented Incidents\n# Conclusions and Follow-up\n## Findings of Bullying or Retaliation\n## Contacts and Action Taken\n## Safety Planning and Follow-up","[{\"question\":\"匿名上报是否会导致对被指控者的纪律处分？\",\"answer\":\"可以匿名提交，但不会仅依据匿名报告对涉嫌施害者采取纪律处分。\"},{\"question\":\"表格要求提供哪些事件基础信息？\",\"answer\":\"需要填写受害者与施害者姓名、事件日期与发生时间、尽可能具体的地点。\"},{\"question\":\"调查结论确定为霸凌或报复后，后续流程包括什么？\",\"answer\":\"需完成结论与调查记录，进行目标与施害者的后续跟进、安全计划，并记录报告转交情况；调查完成后还应上传副本到霸凌追踪系统并将原件放入学校霸凌档案册。\"}]","BULLYING PREVENTION & INTERVENTION - INCIDENT REPORTING FORM | PDF",1790098257]