KILLINGLY PUBLIC SCHOOLS
REPORT OF SUSPECTED BULLYING BEHAVIORS
Name of Person Completing Report:
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Date:
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Month
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Day
Year
Date
Individual Attending School at:
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Please Select
KHS
KIS
KMS
KCS
GECC
Other
Relationship of Reporter to Target (self, parent, teacher, peer, other):
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Report Filed Against:
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Date(s) of Incidents:
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Location(s):
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Time(s):
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Describe the basis for your report Include information about the incident participants, background to the incident, and any attempts you have made to resolve the problem. Please correspond relevant dates, times, places, and behaviors:
Indicate if there are witnesses who can provide more information regarding your report. If the witnesses are not school district staff or students, please provide contact information (telephone, email, etc). If "yes" please describe the behavior of concern, the approximate date(s) and the location:
Have there been previous incidents?
YES
NO
If "YES" please describe the behavior of concern the approximate dates/location:
If "YES" to whom was the incidents reported and when:
Was the report verbal or written?
PROPOSED SOLUTION
Indicate your opinion on how this problem might be resolved in the school setting. Be as specific and detailed as possible:
Certification
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I certify that the above information and events are accurately depicted to the best of knowledge.
Signature of Reporter
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Date Submitted
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Month
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Day
Year
Date
Report Received By:
Date Report Received:
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Month
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Day
Year
Date
Has reporter requested anonymity?
YES
NO
Other
Does the school have parent / guardian consent to disclose the student's name in connection with the investigation?
YES
NO
Other
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