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Bullying Report
Please complete the whole form, responding only to the questions that you feel comfortable answering and are able to answer accurately. You may choose to include your name or submit it anonymously. Please note that the district's ability to investigate an anonymous complaint may be limited, and the District prohibits retaliation against anyone who files a bullying report.
In as concise as possible, describe what happened or what is happening. Though the text spaces on this form appear small, you have around 900 characters to type a description. If you need more, you may submit this form again.
What happened or is happening?
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When did it happen?
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Before school
During school
After school
I am unsure
What day did this happen?
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Most days
I am unsure
What time did it happen? Answer to the closest approximate time.
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Where did it happen. If "other" please describe it.
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In the school building
On the school playground
On the school bus
Online
At a school event
Other
Other
Who was committing the bullying? If you don't know the bully's name(s) describe them as much as possible.
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Who was the target of the bullying? (If you don't know the name, please describe them.)
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Did anyone else witness the bullying? If yes, please list the names if possible.
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No
I am unsure
Yes (Please list the names.)
Yes (Please list the names.)
Was there damage to anyone's personal property?
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No
I am unsure
Yes (Please explain the damage.)
Yes (Please explain the damage.)
Have you or the victim missed any school or made any changes to your daily routine as a result of the incident(s)?
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No
I am unsure
Yes (Please explain the changes.)
Yes (Please explain the changes.)
Have you told anyone about the bullying?
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Parent
Babysitter
Brother/Sister
Other Family Member
Teacher
Other school staff
Friend
No one
Other (Please explain.)
Other (Please explain.)
Have you previously filed a bullying report? (This information is used to determine if retaliation is occurring.)
*
No
Yes
If you wish to give us your name, please type your name, grade and age here.
If you wish you can leave a phone number for us to contact you.
I do not wish to be contacted.
Phone number
Phone number
If you wish, you may leave an email address for us to contact you.
I do not wish to be contacted
Email Address
Email Address
If there is another way that you wish to be contacted, please tell us how we may do that.
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