Richland One Bullying Report
Select whether you are the:
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Target of the bully
Reporter (not target)
Select whether you are the:
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Student
Parent
If student, state your grade level and school name (Ex: 4th Brockman Elementary):
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Your contact information/telephone number:
*
Your E-mail Address:
*
example@example.com
Name of Target:
*
First Name
Last Name
Name of Aggressor:
*
First Name
Last Name
Date/Time of Incident (Example: 03/05/2021 at 11:30 A.M.
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Describe the frequency with which this type of incident occurs (Ex: Occurs on a regular basis, repeatedly occurs on the bus, first occurrence):
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Location of incident (Be as specific as possible):
*
Witnesses #1 (List people who saw the incident or have information about it):
First Name
Last Name
Witnesses #2 (List people who saw the incident or have information about it):
First Name
Last Name
Witnesses #3 (List people who saw the incident or have information about it):
First Name
Last Name
Describe the details of the incident (Include names of people involved, what occurred, and what each person did and said, including specific words used):
*
Submit
Should be Empty: