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Bullying Report Form 2022-2023 District 91
Report incidents of bullying using this form. Reports are anonymous.
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* Indicates required question
Date Time
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MM
/
DD
/
YYYY
Time
:
AM
PM
In which District 91 school did the alleged bullying incident occur?
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Choose
Kelvin Grove Middle School
Milne Grove Elementary School
Both Kelvin Grove & Milne Grove Schools
Name (Optional)
Your answer
Alleged Student Bully(ies)
*
Your answer
Alleged Student Bully(ies)
Your answer
Alleged Student Bully(ies)
Your answer
Alleged Student Target(s)
*
Your answer
Alleged Student Target(s)
Your answer
Alleged Student Target(s)
Your answer
Describe the events that have occurred.
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Your answer
How long has this been happening? Be specific.
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Your answer
When and where is this happening? (Lunch room, locker room, playground, etc.)
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Your answer
What did you do when it happened? List the ways you have responded (if any).
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Your answer
Witnesses (adults or students) who might have observed the incident(s).
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Your answer
Who have you reported this to?
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Nobody
Parent / Guardian
Teacher
Counselor / Student Social Worker
Bus Driver
Building Principal
Superintendent
Other
Required
Name of person you reported this to (if any):
Your answer
What would you like for an adult to do to help you? (Example: listen to me, talk to the students, watch for similar behavior, etc.)
*
Your answer
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