KENEDY INDEPENDENT SCHOOL DISTRICT STUDENT BULLYING REPORT FORM
STOP BULLYING
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: *
Your answer
Date of Occurrence. *
MM
/
DD
/
YYYY
Time of Occurrence. *
Time
:
When did it happen? *
Required
Where did it happen? *
Required
Who was committing the bullying? (If you don’t know the bully’s name(s) describe him/her.) *
Your answer
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.
Your answer
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.
Did anyone else witness the bullying? *
Were you or others physically hurt? (Please explain.) *
Your answer
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? *
Next
Never submit passwords through Google Forms.
This form was created inside of Kenedy Independent School District. Report Abuse - Terms of Service - Additional Terms