Bullying Report Form
Please use the following form as one option to report instances of bullying. Please feel free to contact a building administrator if you have additional information that needs to be shared.
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Person making report (optional)
Your relationship to victim
If reported to you by someone else, indicate who
Date(s) of Incident
Describe the bullying incident in as much details as possible.
Type of bullying
Non-Verbal (exclusion, eye-rolling)
Who was Bullied? (Please list first and last names and grade level of all students, if reporting multiple students.)
Who did the Bullying? (Please list first and last names and grade level of all students, if reporting multiple students.)
Were there any bystanders? If yes, please list first and last name.
Has this happened before?
No, this is the first time
Yes, this has happened before
This is an ongoing issue
*Briefly describe the incident
Any other information we need to know?
By completing this form, you are verifying that your statements are true and accurate to the best of your knowledge.
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This form was created inside of Leeton R-X School District.