Name:
Grade:
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5
6
7
8
Date Incident Occurred:
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Location of Incident:
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Classroom
Hallway
Lunchroom
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Bus
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Type of Incident:
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Verbal
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Emotional
Exclusion
Cyber
Have you reported the incident to an adult?
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Your role in the incident:
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Victim
Witness
Has this type of incident happened before?
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