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Bullying Reporting Form
Dignity for all students (Bullying, Harassment and Hazing)
Date of Incident
MM
/
DD
/
YYYY
Name(s) of alleged offender(s) (Bully) if known:
Your answer
Name(s) of possible witnesses/bystanders:
Your answer
Description of incident:
Your answer
When did this happen? Is this the first time?
Your answer
Did physical injury result from this?
Your answer
Name of person reporting incident (may be anonymous). If you leave your name you will be contacted by Mr. Swick or Mrs. Griffin as soon as possible.
Your answer
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