Bullying Incident Report Form
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Email *
Your Name
Phone Number(s)
Indicate the appropriate response to the following with a check mark(s)
You are a
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Date(s) of alleged bullying
Name of student(s) subjected to bullying:
Person(s) alleged to have committed the bullying or harassment:
Summarize the incident(s) or occurrence(s) of bullying as accurately as possible.
Names of Witnesses:
Have you reported this to anyone else:
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If you have reported this to anyone else - please state who
*Signature of Complainant - Students have the right to complete this form anonymously. However, it will be easier for the District to investigate this matter if as much information as possible is provided. Submission of a good faith complaint or report of bullying or harassment will not affect the complainant or reporter's future employment, grades, learning, or working environment. A complainant that falsely accuses someone will be subject to disciplinary action.
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