Bullying Incident Report
If you have been the target of bullying or have witnessed the bullying of a Kosciusko School District student, you may complete the form below. Information submitted will be forwarded to the building principal where the incident occurred during normal school operating hours. Reports of bullying will be investigated and disciplinary action will be taken if warranted.
You have the right to complete this form anonymously; however, it will be easier for the school to investigate this matter if as much information as possible is provided. By completing the form below, you are certifying that you are making a good faith & as truthful as you know report of bullying behavior. A complainant that knowingly falsely accuses someone could be subject to disciplinary and possible other legal action.
Today's Date
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Your Name
Your answer
Contact Phone Number:
Your answer
School where the incident occurred
Check the box of the person reporting the bullying (the person who is filling this form out) *
Required
Date of the bullying incident *
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Person(s) alleged to have committed the bullying behavior *
Your answer
Where did the incident(s) of alleged bullying occur? Choose all that apply
Column 1
On school property
On a school bus
At a school sponsored event/activity
On the way to & from school
Other
Summarize the alleged incident(s) or occurrence(s) of bullying as accurately as possible *
Your answer
Did the alleged bullying behavior described above meet any of the following criteria?
Names of Witnesses *
Your answer
Is this the first incident you are aware of? *
Have you reported this to any one else? *
If you said yes above, please explain who you reported to
Your answer
I certify that this report is being made in good faith and the details I have provided are true and accurate as far my understanding *
Submit
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