Bullying/Harassment Form
Please complete all of the information below to the best of your knowledge. By filling out this form, I realize that I am responsible for being truthful and that I may be called back in for questioning.
Name person reporting incident
Your answer
I am:
Todays Date
MM
/
DD
/
YYYY
Name of person being bullied/harassed (victim)
Your answer
Name of person allegedly bullying or harassing
Your answer
Describe the incident or allegation. (Use names instead of he/she and be specific)
Your answer
When and Where did this take place?
Your answer
Who were witnesses that directly saw/heard this happen?
Your answer
You can contact me by:
Phone Number (if not a student)
Your answer
By filling out this form, I hereby attest that all information I have given is true.
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