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Date of Incident
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MM
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DD
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YYYY
Time of Incident
Time
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AM
PM
Victim's Name
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Bully's Name
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Your answer
Location of Bullying
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Your answer
Type of Bullying
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Cyber Bullying - cell phone or Internet
Disability Bullying - actual or perceived disability
Lies and Rumors Bullying - spreading lies and/or false rumors
Physical - size, power, and fear to include hitting, kicking, shoving, and spitting
Property Bullying - taking or damaging property of others
Racial Bullying - race, color, or national origin
Sexual Bullying - gender or sexual orientation
Social Bullying - social exclusion or isolation
Threats or Force Bullying - threatening or forcing others to do something
Verbal Bullying - making derogatory comments or statements
Other:
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Incident Description
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Your Name (optional)
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Your Phone Number (optional)
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Your E-mail Address (optional)
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This form was created inside of Niles Township District for Special Education #807.
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