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Anonymous Bullying Report
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* Indicates required question
Name (optional)
Your answer
School Name
Barrie Elementary
Luther Elementary
Purdy Elementary
Rockwell Elementary
Middle School
High School
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Victim's Name(s)
*
Your answer
Name of person(s) doing the bullying
*
Your answer
Witness(es) name(s)
If any.
Your answer
Where did the bullying happen?
*
Your answer
How long has the bullying been going on?
*
Your answer
What have you done about this problem?
Your answer
Have you talked to anyone about this already?
(Student, Teacher, or Other Adult)
Yes
No
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Who do you want to talk to about the problem?
*
Principal
Counselor
Teacher
Other:
What do you want to happen now?
*
I just want someone to know
I want an adult to talk to the person who is doing the harassing/bullying
I want an adult to help me and the person(s) doing the harassing/bullying to solve the problem
I want an adult to try to stop the bullying/harassment
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