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Student Harassment/Bully Incident Form
Your Name: *
Your answer
Student ID # *
Your answer
Grade *
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Grade *
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Today's Date *
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Who harassed or bullied you? (It's okay if you don't have a name) *
Your answer
How often has this person(s) harassed/bullied you? *
Your answer
Describe what happened. (Bully behaviors can be physical, verbal, written or social harassment against your body, emotions, property, sexuality, spirituality,race/ethnicity and relationships. Bullying can take place by an individual or in a group. Remember to report weapon use.) *
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When did it happen? *
Your answer
Where did it happen? *
Your answer
How threatened do you feel by this person? *
Who witnessed the incident? *
Your answer
Name of staff person/teacher/parent (if any) who assisted the student with this report: *
Your answer
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