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Bullying / Harassment Complaint Form
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(Optional) Complainant's Name
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(Optional) Address:
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(Optional) Telephone:
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Name of Individuals Involved
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Type of Bullying / Harassment
What was Done?
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Who was responsible for Bullying/Harassment
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Date and Time of Incident
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Was it the first and only incident
Did it occur more than once?
Is it still going on?
Location of incident
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Describe the incident and the circumstances in which the incident took place: what was your reaction? How did this make you feel?
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Did you talk to anyone after the incident? Give Details:
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List witnesses to the Bullying / Harassment
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(Optional) Complainant's Signature
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Date
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