Bullying Prevention and Intervention Form
Please complete this form to report any bullying instances at CES.
Please fill out the information below. Reports may be submitted anonymously, but no disciplinary action will be taken against an aggressor on the basis of an anonymous report. Questions marked with a red asterik (*) are required.
You are the:
Target of the bullying
Reporter/Witness of the bullying
What is your role?
Please provide your contact information (e-mail or phone number):
If you are a student, please provide your school and grade level:
If you are a staff member, please provide which school you work out of:
Information about the incident
Please be as specific as possible when providing details.
Name of the person(s) being targeted:
Name of aggressor (if known):
Date of Incident:
Time (if known):
Location (ie playground, classroom, gym) of the incident:
Is this a repeat occurrence?
Name(s) of any witnesses:
Please describe what happened (please be as specific as possible using names, dates, locations)
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