Bullying, Harassment or Intimidation Reporting Document
Directions: Bullying, harassment, or intimidation are serious and will not be tolerated. This is a form to report alleged bullying, harassment or intimidation that occurred on school grounds, in a vehicle owned, leased, or contracted by the school being used for a school purpose by a school employee or designee, or at school-sponsored activities or school-sponsored athletic events. Defined: Bullying means any ongoing pattern of physical, verbal, or electronic abuse.
If you are a student victim, the parent/guardian of a student victim, a close relative of the student victim, or a school staff member and wish to report an incident of alleged bullying, harassment or intimidation, complete this form and contact the school's administration.
Buffalo Hills Elementary
Horizon Middle School
Kearney High School
Sunrise Middle School
Windy Hills Elementary
Person Reporting Incident (first and last name)
Person Reporting Incident (telephone number)
Person Reporting Incident (email address)
Person Reporting Incident (check appropriate box)
Parent/Guardian of student
Close relative of student
Name, Age and School of alleged student victim(s)
Name, Age and School of alleged witnesses?
Name, Age and School of alleged offenders?
What date did this alleged incident happen?
Where did the alleged incident happen?
On school property
At a school-sponsored activity or event off school property
On district provided transportation
On the way to / from school
Via electronic device: phone or computer off school property
Via electronic device: phone or computer on school property
Check the statement(s) that best describe what happened (choose all that apply)
Any bullying, harassment or intimidation that involves physical aggression
Getting another person to hit or harm the student
Related to the student's disability
Demeaning and make the victim of jokes
Making rude and/or threatening gestures
Intimidating, extorting or exploiting
Spreading harmful rumors or gossip
Sexual in nature
Cyber bullying (use of social media)
Related to the student's perceived sexual orientation
Electronic Communications (text, email, phone calls)
Human trafficking / prostitution recruitment
Teasing, name calling, making critical remarks or threatening, in person or by other means
Describe the incident, including what the alleged offender(s) said or did
Why did the bulllying, harassment or intimidation occur in your opinion?
Did a physical injury result from this incident?
Did the injury require medical attention?
Was the student victim absent from school as a result of the incident?
Is there any other information you would like to provide?
Send me a copy of my responses.
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This form was created inside of Kearney Public Schools.