Anonymous Bullying Form

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This form is anonymous and confidential. It should only be used when you are feeling a real concern for the physical, social or emotional well-being of yourself or a fellow student. Upon submission of this form a request will be sent anonymously to the building counselor and principal. If you feel this is an emergency, we encourage you to report this immediately to a trusted adult.

If you would like to leave your name, please do so below. This is optional.

Where did the incident that you are reporting happen?

Please type the name of the student that you are concerned about. *

Please describe the problem or incident that you witnessed/heard that you are concerned about. *

What is the approximate date and time this incident occurred?

YYYY

Time

How often is this occurring?

Everyday

A couple of times per week

A couple of times per month

It has only happened once

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