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Anonymous Bullying Reporting Form
Ambrose Elementary School
Note: The information provided will remain anonymous.
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* Indicates required question
Date of Incident
*
MM
/
DD
/
YYYY
Time of Incident
*
Time
:
AM
PM
Location of Incident
*
Your answer
Persons Involved
*
Who was involved in the incident that you are reporting? Include the first and last names (if you know them) of the targets, agressors, and any witnesses that were present.
Your answer
Please describe the incident with as much detail as possible.
Use as many direct quotes spoken by the person and/or describe actions in as much detail as possible.
Your answer
Have there been any past incidents with the person(s) that you are reporting? Has this person done anything else in the past that you are aware of? Please describe.
Your answer
Have you told your parents/guardians?
Yes
No
Other:
Clear selection
Are you concerned about retaliation?
Yes
No
Clear selection
I certify that the information I am providing is accurate to the best of my knowledge. I also understand that false reporting is subject to criminal prosecution.
*
Agree
Disagree
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