Bullying Prevention & Intervention Anonymous Incident Reporting Form

Page 1 of 1

	Anonymous and incomplete reports will be thoroughly investigated. However please enter as much information as possible so we can expedite the investigation process.

1.	Choose a School (select one only)::*
	Choose a School (select one only)::* KP Middle School KP High School

	Please provide the following information:

2.	Location(s) of Incident(s):*

3.	Date(s) of Incident(s):*

4.	Time(s) of Incident(s):*

5.	Name of Target (of behavior):*

6.	Name(s) of Aggressor(s) (Person(s) engaging in behavior):

7.	Check whether you are the:
	Check whether you are the: Target of the Behavior Reporter (not the target)

8.	Check whether you are the:
	Check whether you are the: Student Parent Employee Volunteer Other

9.	Witnesses Please list name(s), role(s) and affiliation(s) of anyone who may have witnessed the incident or have information about it:

10.	Incident Details Describe the details of the incident (including names of the people involved, what occurred and what each person did and said, including specific words used).:

11.	Name of Person Filing this Report (Optional):

12.	Contact Phone (Optional):

13.	Contact email (Optional):

Done

Save

Cancel