Bias Based Incident Reporting Form - Mount Greylock Regional School District

This form will be submitted to the building Principal and Superintendent of schools.

Name of Reporter/Person Filing the Report (Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.)You may choose to write anonymous if you choose.

First Name

Last Name

You may choose to write anonymous if you choose.

Your contact information/telephone number:

Not required if you wish to remain anonymous.

Measures taken to ensure safety of target and reporter:required

Are you the:required

Target of the behavior

Reporter (not the target)

If "Other," please specify:

Which school?required

Name of target:required

Person who experienced the behavior (if known or unknown)

Name of the aggressor:required

Person who engaged in the behavior (if known or unknown)

Date(s) of Incident(s):required

Time when incident(s) occurred:required

Location of incident(s):required

Please be as specific as possible

List witnesses (people who saw the incident or have information about it). Please list each Witness by Name and identify as Student, Staff, or Other.required

Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used). required

Email Address

If you wish to receive a copy of this form.