School Incident/Concern Report

Knox Bully Report Form

I am a: *

During this incident I was a: *

What is your name? (optional)

If you believe this person should receive consequences for their actions beyond a conversation, we need to know the name of the person reporting. Your name can be kept confidential and will not be released to the person you are reporting if you are not comfortable.

What grade are you in?
6
7
8

What is the name of the student you would like to report? *

If you do not know the name of the student, please describe the person.

Where did this incident take place? *

Please describe the incident. *

Were there witnesses to this incident? *
Yes
No

What are the names of the witnesses?

Please rate the severity of this incident from your perspective, 1 being minor incident but unacceptable to 5 being major incident, could result in retaliation or violence. *
1
2
3
4
5

Please describe the frequency with which this type of incident occurs. *

Did this or other incidents make you feel like harming yourself or others? *
Yes
No

Would you like to speak with a counselor or an Administrator? *
Yes
No
If you did not add your name at the beginning of the survey then you must add it here if you want a counselor to follow up with you.

What else would you like us to know about this incident? (optional)



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