Bullying Incident Report
Today's Date *
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Date of Incident *
MM
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DD
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YYYY
Time of Incident *
Time
:
Repeat Infraction? *
Location of Incident? *
First Name of Victim *
Last Name of Victim *
First Name of Bully *
Last Name of Bully *
Name(s) of Witnesses/Bystanders? *
Type of Bullying? *
If you answered physical for the type of bullying, has the victim received an injury from being bullied?
Clear selection
If you answered physical for the type of bullying and the victim has received an injury from being bullied, did the victim report it to the School Nurse?
Clear selection
Bullying Behaviors *
Required
Reported to the School By: *
Required
Describe the Incident. *
Do you have Physical Evidence? *
Required
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