BELLOWS FREE ACADEMY
Hazing, Bullying, Harassment Incident Report

Name of Person Reporting Incident:                                                                                                       Grade:                     

Name of Suspected Perpetrator:                                                                                                             Grade:                     
Did the Reporter (check appropriate box)           witness behavior         receive a complaint         or both

Time of incident:                                   Date incident occurred:                                    Location of incident:                               

Witnesses: (list names)                                                                                                                                                                

Description of Incident and Action Taken by Staff:
                                                                                                                                                                                                   
                                                                                                                                                                                                   
                                                                                                                                                                                                   
                                                                                                                                                                                                   

Who else was involved in the incident and give any other relevant background information:
                                                                                                                                                                                                   

TO BE COMPLETED BY COMPLAINANT ONLY

Name of Complainant:                                                                                                                                                               
    1.    Indicate any changes from the above information here:                                                                                                                                                        
                                                                                                                                                                                                    

    2.    How did the allege perpetrator's remarks/actions affect you and how did you react?                                                                                                      
                                                                                                                                                                                                                                                                     

    3.    How do you want the situation handled?                                                                                                                                     
                                                                                                                                                                                                    

Reporter's Signature:                                                                                                            Date:                                                     

Complainant's Signature:                                                                                                       Date:                                                    

Action taken by Administration:                                                                                                                                                       
                                                                                                                                                                                                   
Nature of Complaint:  (Circle One)

Race            Color            Creed            National Origin            Marital Status            Gender            Sexual Orientation            Disability
Other:                                                                                                                                                                                                                                                         

Administrator's Signature:                                                                                                                                       Date:                                                                     

                                                                                                                           Type of Incident
                                                                                           _____Hazing  _____Harassment  _____Bullying