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Bullying Incident Reporting Tool

Incident Information

Please tell us who is reporting the incident:

Student

Parent / Caregiver

Community Member

Date of incident:

Time of incident:

Name of School:

Specify Location (if applicable):

Type of Bullying:

Physical bullying

Verbal bullying

Social / Relational bullying

Cyberbullying

Definitions

Physical bullying - for example, hitting, pushing, tripping, stealing, or damaging property.
Verbal bullying - for example, name-calling, threats, humiliating, mocking, or making sexist, racist, or homophobic comments.
Social/Relational bullying - for example, excluding a peer from a group, spreading gossip or rumours, making a peer look foolish, or deliberately damaging a peer's relationships.
Cyberbullying - for example, sending, posting, or sharing negative, harmful, false, private, or malicious content about a peer using text messages, apps, social media, forums, websites, or gaming.

Please include as much information as possible:

What happened?
Who else has been impacted or harmed by what happened?
What needs to happen in order to make things right again?

Do you wish to be contacted?

Yes, please contact me.

No, I would prefer that you do not contact me.

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Personal information on this form is collected, used and disclosed in accordance with the Education Act, R.S.O. 1990, c.E.2, as amended and the Municipal Freedom of Information and Protection of Privacy Act. R.S.O 1990, c.M. 56, as amended and will be used for the purpose of investigating reported incidents and any similar or related purpose(s). Questions about this collection, use and disclosure should be directed to the Freedom of Information Coordinator, District School Board of Niagara, 191 Carlton Street, St. Catharines, ON L2R 7P4 905-641-1550.