Bullying/Harassment Report Form - Kewaskum School District

Bullying / Harassment Report Form:

Your Name

Situation:

Grade Level of Bully:

(1 required)

Name of Bully or Bullies:

Targeted Person (People):

Time Period:

(1 required)

	Before School
		1st Block
		Passing time between 1st and 2nd Block
	2nd Block
		Passing time between 2nd and 3rd Block
		3rd Block
	Passing time between 3rd and 4th Block
		4th Block
		1st Lunch
	2nd Lunch
		3rd Lunch
		After School

Location of Bullying:

If you don't know the name of the person, will you be able to identify them with a photo?

	Yes
		No

Are other people aware of the bullying?

	Yes
		No

10.

If yes, who?

11.

Incident(s) / What happened?

12.

Who would you feel comfortable talking to about this situation? You may choose more than one person.

(1 required)

	Ms. Dreher (assistant principal)
		Mr. Fischer (principal)
	Mr. Dunn (school counselor)
		Mr. Rockhill (school counselor)
	My Advisor
		A Teacher
	A Peer 4 Peer student

13.

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.

Type in the text that you see above:

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