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HMS Report-A-Bully
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Email address
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Your email
Today's Date
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MM
/
DD
/
YYYY
Current Time
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Time
:
AM
PM
Main bully's first and last name (or other information that will help us identify him/her.)
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Your answer
Do you know this main bully?
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Yes
No
Second bully's first and last name (or other information that will help us identify them.)
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Your answer
Do you know this second bully?
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Yes
No
Victim's first and last name or other information that will help us identify them.
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Your answer
Date of the bullying incident.
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MM
/
DD
/
YYYY
Time of the bullying incident.
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Time
:
AM
PM
Where did this incident occur?
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Your answer
Please give us the names of witnesses or bystanders who might also have seen this happen:
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Your answer
Describe in as much detail as possible, what the bully did to the victim:
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Your answer
Have you told any teacher, school administrator, parent or other adult about this incident?
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Yes
No
If you answered yes, who did you speak with and when?
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Your answer
I am a(n):
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HMS Parent
Parent
Student
Other:
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