Exhibit- Report Form for Student Bullying and/or Sexual Harassment
To be completed by the bullying target, witness, or person with actual information regarding the incident.  Please complete the form in its entirety and check all appropriate boxes.
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Email *
Person reporting incident:
Name:
*
Relationship to student: *
Required
If other was selected above, please describe the relationship with student
Check here is you wish to remain anonymous
Clear selection
Are you the target of the incident *
If no, was selected above, please give the name of the person targeted
Grade of targeted person *
Required
School *
Required
Date of incident *
MM
/
DD
/
YYYY
Time of incident *
Time
:
Name (s) of persons being reported as aggressor in bullying/sexual harassment. Please provide name, and if the the aggressor is student or staff *
Student was targeted in the following way(s):  *
(check all that apply)
Required
If other was selected above, please describe in detail how the student was targeted
Student(s) were targeted in the following location(s):  *
(check all that apply)
Required
If other was selected above, please describe the location(s) of the incident
Please tell us about the incident in your own words. Use as much detail as possible, including witnesses, what was said, and where the incident occurred. *
The above information is true and accurate to the best of my knowledge.  I understand that giving false information may result in disciplinary action against me.  Please provide a working contact phone number below in case the District may need to contact you. *
A copy of your responses will be emailed to the address you provided.
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