Anonymous

							                  Mohawk Trail Regional School System
                              Office of Curriculum and Assessment
                          24 Ashfield Road, Shelburne Falls, MA 01370

                                 Stop•A•Bully


                           Safe & Anonymous


This form may be used to report bullying, harassment, or retaliation.
Date:
Submitted By: (optional)
School:
Name of Bully:
Grade of Bully:
Date of Incident:
Details of Incident:




Location of Incident:
Time of Incident:
Number of Witnesses:
Who has been told:
Number of times this has happened:

It is the responsibility of the school to investigate the accuracy of every Bully Report and then take the
steps necessary to stop any further bullying/harassment. The Mohawk Trail Regional School System
agrees to treat reports in a professional manner and respect the person who submitted it in their desire to
remain safe and anonymous. This report is considered confidential whether you choose to remain
anonymous or not. School staff will show it only to the persons who are directly involved in this
incident. Anonymous information cannot be used by itself for disciplinary proceedings, but it may
lead to an investigation into the allegation.

      Submit completed form by mail or e-mail to concerns@mohawkschools.org