Harassment Intimidation Bullying Incident Report Form
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Students found responsible for deliberately making false reports may be subject to a full range of disciplinary consequences.

Name of person completing the form: (Contact information if possible)
Your answer
Name of person(s) targeted:
Your answer
Name of the person or people identified as the alleged aggressor(s):
Your answer
Select the school building of the person being targeted:
What type of bullying are you reporting?
Incident Date (When did this happen?)
MM
/
DD
/
YYYY
Incident Time (When did this happen? If possible.)
Time
:
Incident Place: Describe where the incident(s) have taken place.
Your answer
Incident Duration: (How long has this been going on?)
Your answer
Incident Description: (Share details about what happened.)
Your answer
Were there any witnesses?
Your answer
What strategies have you used to try and deal with the situation?
Your answer
Feel free to add additional information that may help the administrator in completing the investigation into this incident.
Your answer
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