INCIDENT REPORT FORM

SMITHFIELD PUBLIC SCHOOLS

Name: ___________________________ Student ID: _____________________ Grade: ______

Date: ______________ Time: _________ School:____________________________________

Please answer the following questions about this reporting incident: List the name of the alleged harasser/perpetrator. If name is not known, provide any other identifiable information: ____________________________________________________________________________________________________________________________________________

Relationship between you and the perpetrator: ______________________________________________________________________

Describe the incident: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

When and where did it happen?___________________________________________________

Were there any witnesses? [ ] yes [ ] no

If yes, who? ______________________________

Other information, including previous incidents or threats: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I certify that all statements made in the complaint are true and complete. Any intentional false statement of fact will subject me to appropriate discipline. I authorize school officials to disclose the information I provide only as necessary in pursuing the investigation.

Signatures:

Complainant: ______________________________________________

Date: _____________

School official receiving complaint: ______________________________

Date: _____________

School official conducting follow‐up: ______________________________ Date: ____________

This document shall remain confidential

SMITHFIELD INVESTIGATION/RESPONSE FORM

Investigation start date: ___________________

Witness Interviews:

Name:

Brief Summary of Information Provided:

Date:

Documentation Reviewed:

Item:

Brief Summary of Information Provided:

Date:

Other Facts:

Finding: Incident ____ did ____ did not occur.

Date: ______________________

RESPONSE:

____ measures to provide the student with a safe educational environment;

describe in detail: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____ disciplinary action against the perpetrator(s) proposed to school authorities;

____ assessment by school psychologist and/or social worker (for both the victim and the perpetrator);

____ referral for appropriate counseling and/or social services;

____ notification to local law enforcement agency (when circumstances warrant criminal charges;

____ notification to student’s IEP team (when victim is a student with a disability);

____ notification to parents/guardians of the victim and the perpetrator of finding and response, if finding is that bullying occurred (specific information about discipline imposed on the perpetrator may not be disclosed to the parents of the victim)

Investigation/Response completion date ___________________

Follow up to ensure that response(s) are adequate on ________________ (date)

____________________________

Signature of School official designated to conduct investigation

____________________________

Date: ____________________________________________

Determine Response (if someone other than the Principal)

____________________________________________________

Signature of the Principal: ____________________________________________

Date: ______________________________________________

Submit to Superintendent or Designee

ADOPTED: December 4, 2017