Bullying / Harassment Report Form:
Grade Level of Bully:
Name of Bully or Bullies:
Targeted Person (People):
Location of Bullying:
If you don't know the name of the person, will you be able to identify them with a photo?
Are other people aware of the bullying?
If yes, who?
Incident(s) / What happened?
Who would you feel comfortable talking to about this situation? You may choose more than one person.
If you indicated you would feel comfortable speaking with a Peer 4 Peer, a teacher, or your advisor, please provide the name(s) of that individual.
Kewaskum School District
1675 Reigle Drive, Suite 100
P.O. Box 37
Kewaskum, WI 53040-0037