Bullying Prevention and Intervention Form
Please complete this form to report any bullying instances at CES.
Information
Please fill out the information below. Reports may be submitted anonymously, but no disciplinary action will be taken against an aggressor on the basis of an anonymous report. Questions marked with a red asterik (*) are required.
Your Name:
Your answer
You are the: *
What is your role? *
Please provide your contact information (e-mail or phone number): *
Your answer
If you are a student, please provide your school and grade level:
Your answer
If you are a staff member, please provide which school you work out of:
Your answer
Information about the incident
Please be as specific as possible when providing details.
Name of the person(s) being targeted: *
Your answer
Name of aggressor (if known):
Your answer
Date of Incident: *
MM
/
DD
/
YYYY
Time (if known):
Time
:
Location (ie playground, classroom, gym) of the incident: *
Your answer
Is this a repeat occurrence? *
Name(s) of any witnesses:
Your answer
Please describe what happened (please be as specific as possible using names, dates, locations) *
Your answer
Submit
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