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Stark County CUSD #100 Bullying Report Form
Stark County CUSD #100 Bullying Reporting Form
*The information reported on this form will only be viewed by administrators in an effort to resolve the situation.
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* Indicates required question
Today's Date
*
MM
/
DD
/
YYYY
Name of person filling out this form (If submitting anonymously, please do not answer this question)
Your answer
Title of person filling out this form
*
student
staff member
parent/guardian
Other:
Required
Phone number
*
Your answer
Dates Bullying Occurred
*
Your answer
Is this the first incident?
Yes
No
Clear selection
If no, how many times has it happened?
Your answer
Name of student being bullied
*
Your answer
Name of alleged bully/bullies
*
Your answer
Name(s) of witness(es)
Your answer
Where did the bullying occur? (Check all that apply.)
*
on school property
school bus stop
school sponsored activity
to/from school
on school operated vehicle
text/phone/internet/social media
off school property
Other:
Required
What words best describe the bullying? (Check all that apply.)
*
taunting
threat
intimidation
stalking
theft
retaliation
humiliation
exclusion
physical contact
cyber-bullying
Other:
Required
Did physical injury result from the bullying?
*
No physical injury resulted
Yes, medical attention NOT required
Yes, medical attention required
Required
Did the bullying cause the student to be absent from school?
*
No
Yes
Required
Describe the bullying in detail:
*
Your answer
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