Incident Report

Cumberland Public Schools

Use this form to report issues relating to bullying, cyber-bullying, and harassment.

Your Name:

(Optional, but helpful)

Please understand, without providing your contact information it may be difficult to pursue this report.

I am a :

Student

Guardian/Family Member

Other

Describe what happened:

Include information on the aggressor, victim, and witness/bystanders; the more detail you provide the better.

Alleged Aggressor:

School:

Alleged Victim:

Witnesses/Bystanders:

Location:

Date and TIme Incident Occured:

Have you told anyone about this incident? Who? (optional):

Have there been other previous issues with this particular student? Can you briefly describe it?:

Please describe the current situation with as much detail that will help the person looking into the situation.:

What sort of help would you like with this issue?:

Addtional Information:

2602 Mendon Road, Cumberland, RI 02864 (401) 658-1600

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