USD 428 Student Safety Report Form
If you have any concerns about bullying, harassment, sexual harassment or violence, please fill out this form so that USD 428 staff can investigate and take appropriate action to keep the students of Great Bend schools safe.

Your responses on this form will be sent to the Assistant Superintendent's office. This information is confidential and will only be shared with the people directly involved in maintaining student safety.

Bullying is any intentional gesture or written, verbal, or physical act or threat that is sufficiently severe, persistent or pervasive that creates an intimidating, threatening or abusive educational environment for a student or staff member.

Type of Safety Concern *
USD 428 building directly related to incident *
Please enter the name of the person making the report. *
Your answer
Name of Victim(s) or Target(s) *
Your answer
Name of perpetrator(s) or other students involved *
Your answer
Name of any witnesses or bystanders *
Your answer
Description of Incident(s): Please describe Who, What, When and Where the action(s) took place or is taking place. *
Your answer
Do you want a follow up conversation with the principal or counselor of the school? *
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