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Bullying Complaint Form
Please tell us your Name (Optional, but very helpful.)
I am a
What happened to you or what did you witness? Be as specific as possible.
Name of student(s) who is/are bullying you or someone you else?
Name(s) of student(s) being bullied.
Names of any witnesses.
Where did this incident take place? Please be specific regarding exacting were the incident occurred.
Please be specific regarding exactly where the incident occurred. (In school and outside of school)
When did this incident take place? (Date and Time)
Does any adult in the building know about this? If yes, please provide their name(s).
Disciplinary Action Taken (Faculty Only)
Internal Comments (Faculty Only):
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