Name(s) of alleged offender(s), if known. Please include any information pertaining to the alleged offender(s) including age, grade level, and what school they attend and whether or not they are a student. *
Your answer
Name(s) of alleged witness(es), if known. Please include any information pertaining to the alleged offender(s) including age, grade level, and what school they attend and whether or not they are a student. *
Your answer
Date on which alleged incident happened *
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YYYY
Where did the alleged incident happen? (Check all that apply) *
Required
In what form did the alleged incident occur? (Choose all that apply.) *
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Place a check next to the statement(s) that best describe(s) what happened. *
Required
Why do you believe that the bullying, harassment, or intimidation occurred? (Choose all that apply) *
Required
Describe the incident(s), including what the alleged offender(s) said or did. *
Your answer
Did a physical injury result from this alleged incident? *
To your knowledge, has the alleged victim threatened suicide? *
If the alleged victim has threaten suicide was it (Check all that applies)
Is there any other information you would like to provide?
Your answer
Do you agree that all of the information on this form is accurate and true to the best of your knowledge? *
Your Name *
Your answer
The best way to reach you for more information (If it is by phone, please enter the area code and phone number. If it is by mail, please enter you address and make sure you include the zipcode. If it is by email, please enter in a valid email address.) *
Your answer
Is this the only alleged incident that happened that you are aware of? *
Click Yes to submit form or Click No to add another incident
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