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Bully Reporting Form
Location
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* Indicates required question
What Campus did(is) this occur(ing) on:
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Columbia High School
West Brazos Jr. High
West Columbia Elementary
Barrow Elementary
Wild Peach Elementary
Date of incident:
MM
/
DD
/
YYYY
Date Reporting
MM
/
DD
/
YYYY
Person bullying:
Your answer
Grade of person bullying:
Your answer
Person being bullied:
Your answer
Grade of person being bullied:
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List any bystanders/witnesses:
Your answer
Type of bullying:
Physical
Emotional/Social
Damage to Property
Cyber
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Where did the incident take place? (gym/locker room/cafeteria etc.)
Your answer
When did it take place?
MM
/
DD
/
YYYY
Please describe what happened. Give as much detail as possible.
Your answer
List evidence of bullying if any (letters,text messages, photos, etc.)
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Person making report (optional):
Your answer
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