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Policy on Disruptive Social BehaviourPDF 24
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What kind of incident happened? Was it:
_____ Physical
Acts such as hitting, spitting, kicking, or damaging
your or another student’s possessions.
_____ Social
Excluding you or another student from a group,
telling other kids not to talk to you or another
student. Spreading mean rumors or lies about you or
another student.
_____ Cyber/Online
Occurred on websites or social media, by cell
phone, email or text message.
_____ Verbal
Saying mean or hurtful things or threatening you or
another student.
Please tell us what happened: _________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Who else saw what happened? Write their names and class/sections here:
__________________________________________________________________________________________
__________________________________________________________________________________________
Was an adult nearby? Who?
__________________________________________________________________________________________
Is there anything else you would like to tell us?
__________________________________________________________________________________________
__________________________________________________________________________________________
What kind of support would you like to get from the school?
__________________________________________________________________________________________
__________________________________________________________________________________________
Declaration
I am turning in this form because I am concerned about a hurtful incident that took place and I want things to be
better in the future. The information I have provided in this form is correct to the best of my knowledge.
Signature:
To be filled by the school office
Reviewed by: ______________________________________
Date: ___________________
Policy on Disruptive Social Behaviours, Aitchison College
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