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Bullying Reporting Form
Please fill in all the information. You can to help us stop inappropriate behavior! Please try to give us names or nicknames. Don't worry about the spelling, spell it like it sounds. Do the best you can to remember the date and time. Be sure to identify the school you are from so we can direct your information effectively. Remember that you must answer all questions marked with an asterisk * before you submit the report.
The more information and detail you give, the more effective we can be in investigating and addressing the concern. If there is an immediate concern or you believe bullying is occurring now, go to the office/school employee and report it immediately.
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* Indicates required question
1. Your first and last name:
Your answer
2. Your grade:
*
Your answer
3. Campus Incident Occurred
*
Seashore Learning Center
Seashore Middle Academy
4. Please indicate the day, time and place this incident happened:
*
Your answer
5. What is the first and last name(s) or other information of the person you believe is causing the problem? Describe what the person looks like, their age, grade, clothing, etc.
*
Your answer
6. What is the first and last name(s) of the victim(s) or other information that will help us identify them, such as grade level, age, what the person looks like, what they were wearing, etc.
*
Your answer
7. What happened? Be as detailed as possible.
*
Your answer
8. Have you told a teacher, school counselor, school administrator, parent or other adult about this incident?
*
Yes
No
9. If you answered yes, please indicate who you spoke to and when.
Your answer
10. Your phone number and/or email address:
Your answer
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