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Exploris Anonymous Bullying Report Form
Please complete the form below to report an incident regarding bullying.
Once submitted an email will be generated directly to the school counselor.
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* Indicates required question
Date:
*
MM
/
DD
/
YYYY
Your Name (Optional):
Your answer
Grade:
*
Your answer
Name of person who bullied
*
Your answer
Grade of person who bullied
*
Your answer
I am reporting (please check one)
*
I was bullied
I saw someone get bullied
I am a parent of child who was bullied
Other:
Required
Date it happened
MM
/
DD
/
YYYY
Where did the bullying happen?
*
Your answer
When did the bullying happen?
Before school
After school
Morning
Lunch time
Afternoon
Hallway
During class
Other:
Clear selection
Describe what happened (be as specific as possible)
Your answer
What else would you like us to know about this?
Your answer
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