BULLYING AND HARASSMENT INCIDENT COMPLAINT REPORTING FORM

BULLYING AND HARASSMENT INCIDENT COMPLAINT REPORTING FORM

Hampden Charter School of Science
School*
Name of Reporter:*
2.Check whether you are the:*

Target (of behavior)Reporter (not the target of the behavior)
Check whether you are a*

StudentStaff MemberParentAdministratorOther
3.A. Provide your Contact Information/Telephone#:*
4. If student, select your school:
Grade
Grade Section:
5. If staff member, state your School or Work Site:
6.Information about the incident:
Name of target (of behavior):*
Select*

Studentstaffother
Name of Alleged Person*
Select*

Studentstaffother
Date(s) of incident(s)*
Time(s) when incident(s) occurred:*
7.Witnesses (list people who saw the incident OR have relevant information about the incident):
Name:
Select

StudentstaffOther
Name
Select

StudentstaffOther
8. Describe the details of the incident (names of persons involved, what occurred, and what each person did and said, including specific words used):*
9. Have you taken any action on this matter? (Yes/No) (If "yes" please describe action taken and when)*
Signature of Reporter (Type Full Name)
Date*

MonthDayYear
Date
In accordance with M.G.L. c. 76, s. 5, Hampden Charter School of Science shall not discriminate nor tolerates harassment based on race, color, national origin, creed, sex, ethnicity, gender identity, sexual orientation, mental or physical disability, age, ancestry, athletic performance, special need, proficiency in the English Language or a foreign language, or prior academic achievement. HCSS has a zero tolerance for harassment based on these areas.
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