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Anonymous Bullying, Cyberbullying, Retaliation Report Form

Paterson Charter School for Science and Technology "PCSST" is committed to the safe and supportive development of all students. As delineated in our BULLYING PREVENTION AND INTERVENTION PLAN this anonymous report will be used by school administration to investigate allegations of bullying in our schools. PCSST will make all reasonable attempts to investigate this report, but - due to the anonymous nature of the report - cannot guarantee that any/all of the information contained herein can be verified during investigation. For this reason, we ask you be as specific and as comprehensive as possible in your responses.

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* Required information.
Type of Incident * Select one or multiple applies
Bullying
Cyberbullying
Retaliation to a Report
Other
Does the TARGET, or victim, attend PCSST? *
Yes
No
Do Not Know
If you answered YES to the previous question, which campus does TARGET attends? Please let us know at which Campus does the target, or victim, of the bullying attend.Elementary K-6 --> Wabash AveHigh School 7-12 --> 11th Avenue
Wabash Avenue
11th Avenue
If you answered NO, what is the name of the school district or school the TARGET attends? Where do you know the Target from?
First and Last Name of the TARGET of the bullying? * If you do not know the student's first and/or last name, please try to be as descriptive as possible regarding physcial appearance, clothing, etc.
Does the AGGRESSOR, or perpetrator, attend PCSST? *
Yes
No
Do not know
If you answered YES to the previous question, which campus does the AGGRESSOR attends? Please let us know at which PCSST Campus does the aggressor, or perpetrator, attend.Elementary K-6 --> Wabash AveHigh School 7-12 --> 11th Avenue
Wabash Avenue
11th Avenue
If you answered NO, what is the name of the school district or school the AGGRESSOR attends? Where do you know the AGGRESSOR from?
First and Last Name of the AGGRESSOR of the bullying? * If you do not know the student's first and/or last name, please try to be as descriptive as possible regarding physical appearance, clothing, etc.
Please provide the date and approximate time of day the incident occurred * Please be as specific as possible.
Where did the incident occur? * Please be as specific as possible. If the incident occurred in a school building, please be as specific as possible regarding the location of the incident (e.g., in library computer lab, etc.)
What happened? * Please describe the incident as clearly as possible, including such things as what force, if any, was used, any verbal statement (e.g., threats, requests, reprimands, name-calling, etc.) and what, if any, physical contact was involved.
Were there any witnesses present when the incident occurred? *
Yes
No
Do not know
If you answered YES to the previous question, what are the names of the witnesses? If you do not know the student's first and/or last name, please try to be as descriptive as possible regarding physical appearance, clothing, etc.
Is this report based on your honest belief that the student listed above as the TARGET, or victim, has been bullied/cyberbullied and, to the best of your knowledge, is the information submitted a true and accurate representation of events? *