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Bullying Reporting Form
Whether you are a witness or target in this case, we want to thank you for helping to maintain a positive safe school and a positive learning environment for all of our students.
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* Indicates required question
Email
*
Your email
Today's date
*
MM
/
DD
/
YYYY
Your Name (This report will be held confidential. Your identity will remain anonymous.)
*
Your answer
When did the bullying or cyber-bullying occur? (Please tell us the date it happened in mm/dd/yyyy format)
Name of the Bully (ies)
*
Your answer
Name of Target(s)
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Your answer
Where did this happen (For example, the bus stop, the cafeteria, on the playground, in the restroom, chromebook-(during related arts)
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Your answer
Where there any witnesses? (If yes, please list their names, if you know them)
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Your answer
Description (Describe what happened as clearly as possible with as many details as you can remember.)
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Your answer
Did you report this to anyone? (If yes, please tell us who.)
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Your answer
Grade Level
*
CD-K
1st
2nd
3rd
4th
5th
6th
A copy of your responses will be emailed to the address you provided.
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