PSD Bullying or Harassment Report Form
Email *

Report Form

This is a form to report alleged bullying or harassment on school property; at a school-sponsored activity/event off school property; on a school bus; or through social media, text messages, or email in the current school year.  

Instructions: Please complete this form, responding as accurately as possible. Please note that the district’s ability to investigate an anonymous complaint may be limited.

Arkansas anti-bullying laws require school districts to report to a parent or legal guardian when a student is believed to be the victim of an incident of bullying and to notify the parent or legal guardian of a student who is determined to have been the perpetrator of the bullying incident.

The district prohibits retaliation against anyone who files a bullying report. If you are a victim of bullying, or aware of an individual being bullied and wish to report it, complete this form or contact the school for assistance at any time.  

School *
Name of Person Reporting Incident *
Contact Information of Person Reporting Incident
Email or Phone Number
Check the Appropriate Box *
Required
Perpetrator(s)   -first and last name *
offender, wrongdoer
Victim(s)    -first and last name *
Date of Incident
MM
/
DD
/
YYYY
Time of Incident
Time
:
Location of Incident
Behavior (Check all that apply) *
Required
Describe the Incident:  *
Was the incident reported at that time to anyone? If so, who? *
Has the victim been bullied or harassed by this person before? If so, how many times? Was a report filed?
Did a physical injury result from this incident? 
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