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Student Reporting Form
for reporting bullying, harassment, and other concerns
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* Indicates required question
Today's Date
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MM
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DD
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YYYY
School Name :
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Your answer
Name of the person(s) who experienced the incident :
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Your answer
Contact Information :
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Your answer
Name of person filling out form (You may report anonymously if you prefer, but having this information may help us investigate the concern. Please put N/A if you would like to report anonymously.) :
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Your answer
Name(s) of person(s) of concern :
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Your answer
Describe what is happening or has happened :
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Your answer
Where did it happen?
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Your answer
When did it happen?
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MM
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DD
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YYYY
Who was involved?
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Your answer
Who saw it?
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Your answer
Has this type of behavior happened before? (If yes, please tell us more about it.)
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Your answer
Do you have a teacher, counselor, or advisor supporting you? Who? If possible, would you like this person with you when talking to administration?
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Your answer
Besides stopping the unsafe behavior, what would you like to see happen?
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Your answer
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