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Alleged Bullying Incident Reporting Form
Please fill out this form to the best of your ability and a school administrator will contact you.
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* Indicates required question
Name of Reporter/Person Filing the Report (This line may be left blank if an anonymous report is being made, but no disciplinary will be taken against the aggressor solely on the basis of an anonymous report)
Your answer
How may we contact you? Please provide your preferred phone number or email
Your answer
Check whether you are the:
*
Target of the behavior
Reporter (not the target)
Check whether you are a
*
Student
Parent
Staff member
Administrator
Other
Name of Target (of behavior)
*
Your answer
Name of Aggressor (if known)
Your answer
Date(s) of Incident(s) (if known)
Your answer
Time When Incident(s) Occurred (if known)
Your answer
Location of Incident(s) (Be as specific as possible)
*
Your answer
Witnesses (List people who saw the incident or have information about it)
Your answer
Describe the details of the incident (including names of people involved, what occurred and what each person did and said)
*
Your answer
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