District 96 Bullying Incident Report
Associated District 96 School *
This will route the information to the proper District 96 administrator.
Please select which best describes your position. *
If you are a District 96 student, please select your grade level.
Please provide the date and approximate time of the incident: *
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DD
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Time
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Please select the choice that best describes the location of the incident: *
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Has this incident been previously reported? *
Offender's Name and Age *
This name field is required in order to investigate reported incidents.
Your answer
Victim's Name and Age *
This name field is required in order to investigate reported incidents.
Your answer
Witnesses's Name and Age (if applicable)
Your answer
Please provide a description of the incident using concrete, clear wording: *
Your answer
Please list the behaviors involved in the incident (e.g., stealing, pushing, name calling, etc):
Your answer
Is there a known motivation for the incident and if so, explain:
Your answer
Were District 96 staff notified about the incident and if so, who?
Your answer
Please detail any physical injuries that resulted from the incident.
Your answer
Please detail any property damage that resulted from the incident.
Your answer
Contact Information (Optional)
Name, E-Mail Address and / or Phone Number (Providing this information is optional. However, please note that the ability to fully investigate the incident may not be possible if this field is left blank.)
Your answer
Security Question: 4 + 3 = *
Your answer
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This form was created inside of Riverside Public Schools District 96.