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