Bullying and Harassment Reporting Form

OSSTF District 12 STBU
Student Bullying and Harassment Reporting Form
This form is to be completed by District 12 STBU members when they have been verbally or physically bullied or harassed by a student. All information will be
confidential to the STBU Executive.

Information submitted on this electronic version of the form will be e-mailed to the District 12 Office Administrator to be distributed to the Executive Officer responsible for your school.

Your Name:

School or Worksite:

Contact Information: Work #: Home #: E-mail:
Date(s) of incident:

Was Principal informed?	If yes, date reported:

Is student IPRC'd (if known)?

Details of Incident 1. Type of Incident: Identify by recording one or more of the following letters in the box. A. Physical Injury B. Verbal Abuse C. Threatenting Behaviour D. Damage to personal property E. Emotional Abuse
Other (describe):


2. Location: (room number, hallway, gymnasium ....)

3. Were there witnesses? Yes No

4. Were there outsife agencies involved? Yes No	If yes, specify:

5. Action taken by the principal:

6. Description of Incident

Date Submitted to District 12 Office:

Thank you for submitting this information.