Bullying Report Form
 
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 Bullying Report Form 
The PSB expects that all members of the school community will treat each other in a civil manner and with respect for differences. The PSB does not tolerate bullying or retaliation, in school buildings, on school grounds, or at school-related activities. All staff members who witness or become aware of bullying or retaliation by any student or staff member must inform the Principal/Headmaster/Superintendent or his/her designee immediately. This form may be used for reporting bullying or retaliation. The Principal/Headmaster/Superintendent or his/her designee will investigate all reports of bullying and retaliation and will take prompt action to end the conduct and restore the target's sense of safety. For more information, please refer to the PSB Bullying Prevention and Intervention Plan and Bullying Prevention Policy, available at all schools and on the PSB website. You can choose to file this report anonymously. However, please be advised that no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.

 
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The TARGET is the person being bullied. Choose "Target" if YOU are being bullied or harassed. If you are reporting about someone else being bullied or harassed, you are the "Reporter" and you choose that option.
 
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The TARGET is the person being bullied. Choose "Target" if YOU are being bullied or harassed. If you are reporting about someone else being bullied or harassed, you are the "Reporter" and you choose that option.
    
   
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Entering your telephone number and email address enables the school to get in touch with you. This is optional, but advised.
 
   
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The "TARGET" is the person being bullied or harassed. It may be you, or the person who you are filling out the form for. Enter the name of the person being bullied or harassed.
 
   
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What is the name of the school that the person being bullied attends?
 
   
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What grade is the person being bullied in?
 
   
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The alleged "AGGRESSOR" is the person being accused of bullying or retaliation. Enter the name of the person who is doing the bullying or harassing.
 
   
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What is the name of the school that the accused bully attends?
 
   
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What grade is the accused bully in?
 
   
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Date of the incident being reported, or multiple dates for multiple incidents.
 
   
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Where the bullying or retaliation occurred. This can be one or several locations.
 
   
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Disability: Making fun of someone's "disability" by teasing them about it Race or color: Speaking of someone's race or color using negative words. Sexual orientation: Teasing or bullying, or in any way referencing sexual orientation. Gender discrimination: Bullying or harassment because of someone's gender. Religious discrimination: Making fun of someone's religion, religious practices or customs, religious clothing or jewelry. Age discrimination: Bullying or harassment because of someone's age.
 
  
  
  
  
  
  

    
   
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If there is at least one witness to the bullying or retaliation, put that person's name here. If there is more than one witness, list multiple names.
 
   
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Please describe the details of the bullying or retaliation you experienced, saw or heard about (including the names of all people involved, what occurred, and what each person did and said, including the words used) along with what each witness experienced, saw, or heard. Please use additional space on back if necessary.
 
   
 
 
 
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