Bullying, Harassment or Intimidation Reporting Form 2024-2025

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This form is to be confidentially maintained in accordance with the Family Educational Rights and Privacy Act.

Directions: Bullying, harassment or intimidation is not acceptable. Please complete this form to report alleged bullying, harassment, or intimidation and return it to the school administration office. Contact the school for additional information or assistance at any time.

https://core-docs.s3.amazonaws.com/documents/asset/uploaded_file/488131/kansas_bullying_framework.pdf

Today's Date *

YYYY

Name of Person Reporting Incident: *

Phone number they can be reached at: *

Email address: *

Are you (check one) *

Student / Victim

Student Witness / Bystander

School Staff Member

Parent / Guardian

Close Adult Relative

Other Adult

Required

Name(s) of Student Victim(s): (Please include first and last name) *

Name(s) of Alleged Offender(s): (Please include first and last name) *

Name(s) of Witness(es) / Upstander(s): (Please include first and last name) *

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