Report Bullying
Your Name (Optional, you may report anonymously):
Your answer
Your Grade
Your Age
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How can we contact you?
Phone Number
Your answer
Email Address
Your answer
Other
Your answer
Describe what happened/what is happening
Your answer
When did it happen? (Date)
MM
/
DD
/
YYYY
When did it happen? (Time)
Time
:
Who was committing the harassment/bullying? Name or describe
Your answer
Who was the victim of the harassment/bullying? Name or describe
Your answer
Did anyone else witness the event? Please list witnesses.
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Were you or anyone else physically hurt? Please describe.
Your answer
Have you told anyone about the bullying?
Who have you told about the bullying?
Your answer
Has this harassment happened before?
If so, have you reported this previously?
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This form was created inside of General Brown Central School District.