Bullying/Harassment Report Form
Riceville CSD
Bullying and Harassment Report Form
Please be as detailed as possible when filling out this form
Location of the incident *
Who was/were the vicitm(s)? *
Enter the names below
Your answer
Name of the person reporting this incident
optional
Your answer
Relationship to the victim
optional
What is the name(s) of the accused bully?
If you don't know there name, please provide a detailed description of the individual(s)
Your answer
Where did the incident take place?
Please be specific
Your answer
Date and Time the incident took place? *
MM
/
DD
/
YYYY
Time
:
Describe what happened *
please include as much detail as possible
Your answer
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