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Bullying, Harrassment, and Intimidation Form
This is a confidential report that is emailed only to our school nurse, Mrs. Johnson.
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Name the person/persons bullying me.
Your answer
When did the bullying begin?
Your answer
Where is the bullying taking place?
Your answer
Have you spoken to an adult about this problem?
Yes
No
If yes, whom did you speak with?
Your answer
Did the person spoke with take action?
Yes
No
Do you feel the situation has improved or gotten worse?
Your answer
State any additional information concerning your situation.
Your answer
Student Name:
We will promptly get back to you!
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