5030(E)REPORT OF SUSPECTED BULLYING BEHAVIORS
REPORT OF SUSPECTED BULLYING BEHAVIORS
MERIDEN PUBLIC SCHOOLS
REPORT OF SUSPECTED BULLYING BEHAVIORS OR TEEN DATING VIOLENCE
(School Employees Should File with the School Principal)
(Parents and Students May File with the School Principal or Any Other School Employee)
Name of Person Completing Report:
Date:
Target(s) of Behaviors/Violence:
Relationship of Reporter to Target (self, parent, teacher, peer, etc.):
Report Filed Against:
Date of Incident(s):
Location(s): Time:
Describe the basis for your report. Include information about the incident, participants, background to the incident, and any attempts you have made to resolve the problem. Please note relevant dates, times, and places.
Indicate if there are witnesses who can provide more information regarding your report. If the witnesses are not school district staff or students, please provide contact information.
Name Address Telephone Number
Have there been previous incidents (circle one)? Yes No
If “yes”, please describe the behavior of concern or the violence that occurred; include the approximate date(s) and the location(s):
Were these incidents reported to school employees (circle one) Yes No
If “Yes”, to whom was it reported and when?
Was the report verbal or written?
Proposed Solution:
Indicate your opinion on how this problem might be resolved in the school setting. Be as specific as possible.
I certify that the above information and events are accurately depicted to the best of my knowledge.
Signature of Reporter Date Submitted
Received By Date Received
9/1/2020
Previous Policy Number:
