PC Bullying, Harassment or Intimidation Reporting Form
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Today's Date *
Name of student victim *
Age of student victim *
Grade of student victim *
Name(s) of alleged offender(s) (if known)
Alleged offenders school (if known)
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Where did the incident occur (choose all that apply)? *
Choose the statement(s) that best describes what happened (choose all that apply) *
If you chose Electronic communication or Other in the previous question, please specify.
What did the alleged offender(s) say or do? *
Do you have any information to share about why the bullying, harassment or intimidation occurred? *
Is there any additional information you would like to provide (ex. threats of suicide, legal issues, etc.)?
Person reporting incident contact number
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