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Clarksburg Elementary School Bullying Incident Reporting Form
Name of Reporter/Person(s) Filing the Report
(Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.)
Check whether you are the: *
Check whether you are a: *
Your contact information: email or telephone number (if applicable):
If you're a student, state your grade
Name of Target (of behavior): *
Name of Aggressor (Person who engaged in the behavior): *
Date(s) of Incident(s): *
MM
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DD
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Time when Incident(s) Occurred: *
Time
:
Locations of Incident(s) (Be specific as possible): *
Witnesses (List people who saw the incident or have information about it:
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used). *
eSignature of person filing this report:
Date: *
MM
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DD
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Submit
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