South Jefferson CS Dignity For All Student's Act Bullying Referral
Name
First and Last Name of the person completing this form. You may also report anonymously by entering the word anonymous.
Your answer
Contact Information
(phone number, email address)
Your answer
Relationship
What is your relationship to person being bullied or harassed?
Your answer
Victim's Name
Your answer
Victim's School
Victim's Gender
Your answer
Victim's Grade
Your answer
Accused
Name of person thought to be bullying
Your answer
Accused's Gender
Your answer
Accused's Grade
Your answer
Location of the incident.
Your answer
Incident Date & Time.
Your answer
Describe the incident.
Your answer
List witnesses names and grades.
Your answer
Evidence to support the incident.
Check the items you may have to support this incident.
I agree that all information on this form is accurate and complete to the best of my knowledge.
Required
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