Bullying / Harassment Complaint Form
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(Optional) Complainant"s Name:
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(Optional) Address: *
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(Optional) Telephone Number: *
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Name of individual(s) Involved: *
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Type of Bullying / Harassment: *
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What was done? *
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Who was responsible for Bullying/Harassment: *
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Date and Time of the Incident: *
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Was it the first and only incident? *
Did it occur more than once? *
Did it occur during your school hours? *
Is it still going on ?
Location of Incident: *
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Describe the incident and the circumstances in which the incident took place: what was your reaction? How did this make you feel? *
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Did you talk to anyone after the incident? Give details: *
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List Witnesses to the Bullying/Harassement *
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(Optional) Complainant's Signature:
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Date: *
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