Kewaskum School District Reporting Form
As a district, we would like to address all concerns related to bullying and harassment. To do so requires that we have knowledge of the incident. The form below has been created so that people have a safe way to report bullying and safety concerns. When a person really needs help we hope you will step up and send in a report. Sending in a false report makes it harder for your school to help the people who really need it. You have the option to send in a report anonymously. If you don't want your report to be anonymous then include your name as the reporter in the area that says, What is your name? Including your name means that it will be sent along with the other details of the report.


If you feel unsafe or know someone who feels unsafe, you can report it here. People use this form to report:

1. Bullying, Harassment, or intimidation at school.
2. Bullying, Harassment, or intimidation outside of school.
Cyberbullying (Facebook, MySpace, Text Messaging, Twitter, Instagram, etc.).
3. Fights, drugs, alcohol, or weapons at school.
4. Friends who talk about hurting themselves.

All entries made are confidential. Persons completing this form may remain anonymous.


School Name *
Required
Date(s) of Incident *
MM
/
DD
/
YYYY
When did the incident occur? *
Please check the one choice that best applies
Where did the incident occur? *
Please check the one choice that best applies
During what time frame did the incident occur? *
Please check the one choice that best applies
Please share the name of the person responsible for bullying, harassing, intimidating, or causing harm. *
Include first name, last name, and grade if known. If you can not name them would you be able to identify them via a photo.
Your answer
Please share the name of the person being harmed, bullied, harassed, or intimidated. *
Include first name, last name, and grade if known
Your answer
Describe what occurred *
Include as much specific detail as possible.
Your answer
Please share the names of any witnesses.
Include first name, last name, and grade if known.
Your answer
Who are you?
What is your name?
Optional
Your answer
If you are not a student at this school and would like someone to contact you, please share your phone number.
Optional
Your answer
Submit
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