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Report of Potential Bullying or Retaliation

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Foxborough Public Schools

Report of Potential Bullying or Retaliation

For Staff, Students, and Parents 


Today’s date:            School:  

Name of student target/victim           Grade: 

Name of alleged aggressor/offender(s):      Grade: 


On what date(s) did the incident happen?  

Where did the incident happen? (check all that apply)

On school property

At a school sponsored activity

At bus stop

On a school bus

On the way to/from school

On computer/cellphone or other

electronic device



Put a check next to the statement(s) that best describe(s) what happened:



physical violence

name calling

social exclusion



sexual harassment

cyber bullying


public humiliation

Other (explain in the space below)


What did the alleged aggressor/offender(s) say or do? 


Was the incident an act of retaliation?

If yes,  please explain: 

Did a physical injury result from this incident?

If yes,  please explain:

Did the injury require medical attention?

If yes,  please explain:


Was the target/victim absent from school as a result of this incident?   If yes, how many days? 


Additional information: 


Name of person reporting the incident (This can be reported anonymously): 

Please indicate how you know about the incident: 


Your telephone number:     Your email address:  

Your relationship to the target/victim: 


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