Hatfield Public Schools Incident Report Form

Name of Reporter (may be anonymous):

Date, Time and Place of Incident:

Who Reported the Incident? (circle one)     Student     Bystander     Other Witness to Incident

Name of Target of Behavior:

Name of Aggressor:

Witness/Bystander (others who saw incident or have other information about it):

Description of Incident/ Behavior:

Circle all behaviors that apply to this incident:

Investigation

Investigator______________________________________

Interviews:

Interviewed aggressor             Name                                                   Date

Interviewed target                  Name                                                   Date

Interviewed witnesses                        Name                                                   Date

Name                                                   Date

Any prior documented incidents by the aggressor?                  ___Yes       ___No

If yes, have incidents involved target previously?   ___Yes    ___No

Brief summary of investigation:

(For Administrative Use Only)

Conclusion from Investigation

Finding of bullying or retaliation: ___Yes    ___No

Contacts:

Target’s parents/guardian Date___________________ Aggressor’s parent/guardian Date_________________

Law Enforcement Date________________________

Action taken:

__Loss of privilege

__Detention

__Community service

__Education

__Suspension

__Other

Safety Planning: