Report of Bullying/Harassment Incident
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1.
Name of School:
*
2.
Date of Report:
*
3.
IMMEDIATE DANGER:
If you fear that you or another student is in IMMEDIATE danger, contact your building principal immediately. Please answer the questions honestly and specifically.
4.
Your Name:
5.
Grade:
*
6.
Your Gender:
*
--Please Select--
Male
Female
7.
Gender of the Victim:
*
--Please Select--
Male
Female
8.
What happened?:
*
9.
Where did it happen?:
10.
Who was involved/witnessed the incident?:
11.
Have you spoken to anyone about this incident?:
*
--Please Select--
Yes
No
12.
If yes, who?:
13.
Is this the first time something like this has ever happened to the person that was bullied?:
--None--
Yes
No
14.
What would you like to see as a consequence of the behavior stated above?: