Harassment, Intimidation, Hazing & Bullying Report
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Optional Information
First Name
Last Name
Email
Phone
Incident Information
Enter Incident Information Below
Date of the Incident
MM
/
DD
/
YYYY
Time of the Incident
Time
:
If date and/or time of the incident are unknown, if possible, please give a general timeframe for the incident.
School *
Location *
Required
Please enter more information about the location of the incident to assist in identifying where the incident occurred. *
Your Role *
Please enter any other information about how you were involved or how you know of this incident. *
Type / method of harassment, intimidation, hazing, or bullying *
Required
Please enter as much information as possible about the type / method of harassment, intimidation, hazing, or bullying you are reporting (e.g., electronic communication, written communication, relationship / dating). *
Cause of harassment, intimidation, hazing, or bullying: *
Required
Name(s) of the person being harassed, intimidated, hazed, or bullied? *
Victim's Age *
Victim's Grade *
Who was harassing, intimidating, hazing, or bullying? *
Offender(s) Name *
Offenders Age *
Offender's Grade *
Please provide as much information as possible about the incident, including names of witnesses and exactly what happened. *
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