Bullying Form
BULLYING INCIDENTS CAN BE REPORTED ANONYMOUSLY.

Bullying is defined as any intentional gesture or any intentional written, verbal, electronic 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 that reasonable person, under the circumstances, knows or should know, will have the effect of:

o Harming a student or staff member

o Damaging a student or staff members property

o Placing a student or staff member in reasonable fear of harm to the student or staff member

o Placing a student or staff member in reasonable fear of damage to the student’s or staff member’s property

K.S.A. 72-8256

Name of student target (victim) *
Your answer
Where Does he/she attend school? *
Required
Has the appropriate teacher/coach/bus driver been contacted? *
If yes, please provide the name(s) of who you contacted:
Your answer
Name(s) of alleged bully(ies) (if known):
Your answer
On what date(s) did the incident happen? * *
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Where did the incident happen? Please choose all that apply: *
Required
Please select the statement(s) the best describe what happened. Please choose all that apply: *
Required
What did the alleged bully(ies) say or do? *
Your answer
Why did the harassment or intimidation (bullying) occur? *
Your answer
Were there any witnesses? *
Did a physical injury result from this incident?
If yes, please describe:
Your answer
Was the victim absent from school as a result of the incident? *
If yes, please describe:1
Your answer
Is there any additional information you would like to provide?
Your answer
Name of person reporting (optional)
Your answer
Today's Date: *
MM
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DD
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YYYY
Email (optional):
Your answer
Phone Number (optional):
Your answer
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