Bullying, Harassment and Abuse Incident Report

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SCHEDULE 2 ‐ Bullying, Harassment and Abuse Incident Report The purpose of this form is to provide a method of reporting any incident of bullying, harassment and abuse within  the SMHA. Please refer to the SMHA Bullying, Harassment and Abuse Policy for further clarification about what is a  reportable incident.  Date of the Incident (day/month/year):_______________________ _________Time: __________  Location of the Incident: ___________________________________________________________  Alleged Victim Information 

          

Member’s Name: ________________________  

Birthdate: ___________________   Sex: ____ 

Address: _______________________________  

E‐mail: ______________________________ 

 

_______________________________ 

Parent/Guardian’s Name: ____________________   Phone Number: _______________________                                        

 

 

 

 

Alternate Phone Number: _______________ 

Team: ____________________________________  Division: _____________________________  Alleged Offender’s Information 

         

Name: _________________________________  

Birthdate: ___________________   Sex: ____ 

Address: _______________________________  

E‐mail: ______________________________ 

 

 _______________________________ 

Parent/Guardian’s Name: ____________________   Phone Number: _______________________                                        

 

 

 

 

Alternate Phone Number: _______________ 

Team: _________________________________ 

Division: _____________________________ 

Details of incident: (use a separate page if necessary)  1.

2.

3.

Provide a concise description of what the player disclosed (record only the facts and statements, not  interpretations/opinions.)    Provide a description of your observations of the player(s)      Were there any other factors that could have affected/influenced the incident? 

Witnesses:  Witnessed by: _______________________     SMHA Policy & Information Manual  Revised November 2012|    Page 46 

Phone Number: __________________ 

 

 

                _________________________________________                  _________________________________________                  _________________________________________  If witnesses were present, describe their recollection of the incident:    Person Receiving Disclosure 

          

Print Name: _____________________________  

Date: _____________  Time: ___________ 

Address: ________________________________  

E‐mail: _____________________________ 

 

________________________________ 

Phone Number: __________________________  Position: ________________________________ 

Signature: __________________________ 

Reporting  Was this reported to the Child Protection Agency or Police? ____________________________  If so, by whom? ________________________  

Date: ______________ Time: _________ 

Who received the report? _______________________________________________________  What response did the Child Protection or Police Representative give to the report?    Office Use Only  Proposed Recommendation and Action Plan:  Immediate: 

 

 

 

 

 

Long Term: 

      **Please attach all documents related to this report for final submission to the SMHA. * 

SMHA Policy & Information Manual  Revised November 2012|    Page 47