CHS Bullying Incident Report
*Document MUST be completed within 2 school days of alleged bullying incident.
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Email *
Date:
MM
/
DD
/
YYYY
Reported by:
Student Name:
Alleged Perpetrator(s):
Nature of conduct:
Summary of Incident:
Date event occurred:
MM
/
DD
/
YYYY
Time event occurred:
Time
:
Location:
Any discipline applied at event:
Clear selection
Discipline applied:
Support provided to victim
Clear selection
Support provided:
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This form was created inside of Center School District #58. Report Abuse