Role of complainant (i.e. Parent, Student, etc): *
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Name of student being harassed or bullied: *
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Name of alleged harasser or bully: *
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Date of Incident: *
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Location of incident or incidents: *
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Building harassed student attends: *
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Description of misconduct: *
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Name of witnesses (if any):
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Any other information:
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I agree that all of the information on this form is accurate and true to the best of my knowledge. If you agree with this statement, type your name below. *
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