Preparing Students to Excel and Contribute to their Community
GENOA-KINGSTON CUSD 424
Bullying Report Form
Instruction: Please complete form as detailed as possible. You may respond 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 submit it anonymously. Please note that an anonymous complaint or lack of information limits the administration’s ability to investigate the bullying report.
Definition of Bullying: In order to consider bullying, the behavior must be:
Complete the form and click submit or or click on the following link for a Word document to completed and turn in to the BULLYING REPORT BOX or a Middle School Staff Member.
Bully Report Form
Date of report:
Alleged Student Bully(ies):
Alleged Student Target(s) (Name of victim or listing of witnesses required)
Type of Bullying:
Bullying Behavior: (Check all that apply)
Described what happened in detail:
How long has this been happening? (Be specific)
Where did this happen? (Examples: Bus stop, bus, cafeteria, hallway, classroom, locker room, etc.)