7:180-AP1, E5 Exhibit – Report Form for Bullying and School Violence
To be completed by the bullying target, witness, or person with information about an incident of bullying
or school violence and submitted to the Building Principal’s office. Make readily accessible via
website(s) and other publicized designated areas in schools.
Email address *
School *
Name *
Your answer
Date *
MM
/
DD
/
YYYY
Please select one *
Student
Parent
Staff
Other
Status
Indicate here if you prefer to remain anonymous. *
Yes
No
Yes/No
Are you the target of the bullying or school violence that you are reporting? *
Yes
No
Yes/No
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
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