Bullying / Harassment Report Form:

1.
*

Your Name
2.
*

Situation:
3.
*

Grade Level of Bully:

 (1 required)
Senior   Junior
Sophomore   Freshman
Unknown
4.

Name of Bully or Bullies:
5.

Targeted Person (People):
6.
*

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
7.
*

Location of Bullying:
8.

If you don't know the name of the person, will you be able to identify them with a photo?
Yes   No
9.
*

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:

  

Adjust Font Size: A   A   A   A   A   A

Kewaskum School District
1675 Reigle Drive, Suite 100
P.O. Box 37
Kewaskum, WI 53040-0037

Powered by CMS4Schools