Kit Carson School
* Required
Bullying Report
The contents of this report are strictly confidential. Only the district ADMIN will have access to the records once the forms have been submitted.
What Can I Report
• Safety threats, bullying, harassment or intimidation at school
• Safety threats, bullying, harassment or intimidation outside of school
• Cyberbullying; Facebook, Instagram, YouTube, etc.
• Fights, drugs, alcohol or weapons at school
• Friends who talk about hurting themselves
Where did the incident occur?
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Choose
At an after school activity
At the bus stop
During Recess
In a Text message
In an email
In an instant message
In class
In front of the building
In the bathroom
In the Cafeteria
In the Gym
In the hallway
In the locker room
In the parking lot
On Facebook
On Instagram
On the bus
On the field
In Twitter
On Youtube
Over the phone on on a voicemail
Snapchat
Vine
Other
When did it happen?
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MM
/
DD
/
YYYY
What time did it happen?
*
Before school
Before lunch
After lunch
After school
Required
How many times has this situations happened?
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Choose
This is the first time
One other time
Once a month
Once a week
Once a day
Multiple times a day
Have you reported this to an adult?
*
Choose
Yes
No
Who was bullying, harassing, intimidating or causing harm? Include first name, last name and grade if known.
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Your answer
Who was the person being harmed, bullied, harassed or intimidated? Include first name, last name and grade if known.
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Your answer
Describe what happened. Give as much information as you can. Let us know if there were any witnesses.
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Your answer
Who are you?
*
Choose
Student
Teacher
Staff Member
Administrator
Board Member
Volunteer
Parent
Other
What is your name?
Your answer
If you would like someone to contact you, please add your email or phone number here.
Your answer
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