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Bullying Incident Report
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Today's Date:
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MM
/
DD
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YYYY
When did this incident happen?
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Location of incident:
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Lueders-Avoca High School
Lueders-Avoca Elementary/Junior High
Off Campus
If off campus, please give more details:
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Your role:
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Student
Teacher/Staff
Parent
Bystander
Other
Describe the incident with as many details as possible:
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IF known, what was the cause of the bullying?
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Age
Gender identify
Race
Physical attributes
Physical/mental abilities
Political beliefs
Socioeconomic status
Sexual orientation
Other
Method of bullying:
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Electronically
Written
Verbal
Physical
Other
Who was the person being bullied (victim)?
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What is the victim's age/grade?
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Who was bullying?
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Bully's age/grade?
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Names of any other witnesses:
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*Optional* Your name:
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*Optional* Your contact information (email, phone, etc.)
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