KENEDY INDEPENDENT SCHOOL DISTRICT STUDENT BULLYING REPORT FORM
Instructions: Please complete, responding only to the questions that you feel
comfortable answering and are able to accurately answer. You may choose to include your name
at the bottom of the form or may submit it anonymously. Please note that the district’s ability to
investigate an anonymous complaint may be limited, and the District prohibits retaliation against
anyone who files a bullying report.
Describe what happened/what is happening:
Date of Occurrence.
Time of Occurrence.
When did it happen?
Where did it happen?
In the school building
On the School Playground
At school function or event
School Bus or School Transportation
Who was committing the bullying? (If you don’t know the bully’s name(s) describe him/her.)
Who was the victim of the bullying? (If you don’t know his/her name, describe him/her).
* Please note that the district’s ability to investigate an anonymous complaint may be limited if you do not correctly provide this information. PLEASE LIST A NAME SO WE CAN CORRECTLY INVESTIGATE THE ISSUE.
What campus is the victim of the bullying from?
* Please note that the district’s ability to investigate an anonymous complaint may be limited if you do not correctly provide this information.
Kenedy Elementary School
Kenedy Middle School
Kenedy High School
Did anyone else witness the bullying?
Were you or others physically hurt? (Please explain.)
Was there damage to anyone’s personal property?
Have you or the victim missed any school or made any changes to your daily routine as a result of the incident(s)?
Have you told anyone about the bullying?
Brother / sister
Other Family Member
Other School Staff
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This form was created inside of Kenedy Independent School District.