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KMS Bullying Report Form
Click "Submit" to send the information after you answer the questions below. Your report will go directly to the school counselors and the Student Services Department. Your information will be kept confidential.
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* Indicates required question
Name of person being bullied.
*
Please include first and last name if you know the person's full name.
Your answer
Name of person doing the bullying.
Please include first and last name if you know the person's full name.
Your answer
Where did the bullying occur?
Check all that apply.
Classroom
Hallway
Bus
Cafeteria
Bathroom
Other:
When did this happen?
Date and Time
Your answer
Type of bullying.
Check all that apply.
Physical - Hitting, kicking, or other physical aggression.
Verbal - Teasing, name-calling, put-downs, or other behaviors that would hurt someone's feelings or make them feel bad.
Emotional/Exclusion - starting rumors, telling others not to be friends with someone, or other actions that could cause someone to be without friends.
Cyber Bullying - Using texting, social media (Facebook, Instagram, SnapChat etc), or any other forms of electronic medium to do any of the previously mentioned bullying behaviors.
Please add any additional information that will be helpful in understanding what happened and who was involved.
Your answer
Have you reported the bullying to another adult at school?
If so, include their name.
Your answer
Name of student(s) being an ally.
An "ally" is someone who stands up against bullying and/or who helps others in need.
Your answer
Your name. (Optional)
Your answer
I am a
Student
School Employee
Parent/Caregiver
Community Member
Other:
Clear selection
Did you witness the bullying?
Yes
No
Clear selection
Who else witness the event?
Your answer
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