MMS Safe School Reporting Form - Pomperaug Regional School District 15

Pomperaug Regional School District #15 is committed to creating and maintaining a physically, emotionally, and intellectually safe educational environment free from bullying, teen dating violence, harassment and discrimination.

To report a Suspected Bullying Behavior or Suspected Teen Dating Violence Incident:

All reports may be made anonymously and are available to students, parents/guardians, staff members and others who wish to report an incident.

Required

Name of Person Completing Reportrequired

First Name

Last Name

Reporter's Email Addressrequired

Today's Daterequired

Must contain a date in M/D/YYYY format

Target(s) of Behavior/Violencerequired

Relationship of reporter to target required

Example: self, parent, friend, sibling, etc.

Report Filed Againstrequired

Date of Incidentrequired

Must contain a date in M/D/YYYY format

Location of Incidentrequired

Time of Incident

Describe the basis for your report. Include information about the incident, participants, background to the incident, and all attempts you have made to resolve the problem. Note relevant dates, times, and places.required

Indicate if there are witnesses who can provide more information regarding your report. If witnesses are not school district staff or students, please provide name(s) and contact information for those witnesses (name, address, phone)required

Have there been previous incidents?required

YES

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

YES

If "Yes", to whom was it reported and when?

Was the report verbal or written?

Verbal

Written

PROPOSED SOLUTION: Indicate your opinion on how this problem might be resolved in the school setting. Be as specific as possiblerequired

Would you like to talk confidentially with someone?requiredPlease select up to 1 choice

YES

Please select up to 1 choice

MMS SAFE school coordinator

Jennifer Murphy, Principal

Region 15 Policy on Bullying Prevention and Intervention

Region 15 Non-Discrimination Statement

District-wide and school-based Safe School Climate Committees have been established to further foster safe, engaging learning environments in every Region 15 school. The District Safe School Climate Plan represents a comprehensive approach to address bullying, teen dating violence, and cyberbullying, as well as “mean behavior,” and sets forth the Board of Education's expectations for creating a positive school climate and thus preventing, intervening, and responding to incidents of bullying, harassment, or mean behavior.

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To report a Suspected Bullying Behavior or Suspected Teen Dating Violence Incident:

MMS SAFE school coordinator