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Benson Bullying Report
Benson Bullying Report
Please complete the form below. Required fields marked with an asterisk *
Today's Date
*
Answer Required
I am a:
*
Answer Required
Target of bullying
Witness
Staff Member
Parent/Guardian
Community Member
Other
What date did the incident occur?
*
Answer Required
Name of Alleged Bully
*
Answer Required
What time of day did the incident occur?
Answer Required
Where did the incident occur? IE: Hallway, Classroom, Bathroom, Lunchroom, Bus Stop, Library, etc.
*
Answer Required
Type of Bullying - please choose one or multiple
Answer Required
Relational / Emotional agression
Starting Rumors
Excluding an individual
Telling other not to be friends with someone
Physical Agression
Hitting/Kicking
Verbal Agression
Teasing
Name Calling
Put downs
Behavior that would hurt feelings
Cyberbullying - Texting
Cyberbullying - Social networks (Facebook, etc.)
Cyberbullying - Email
Cyberbullying - Other electronic means
Other:
Has the alleged bully done this to the same victim on other occasions?* (yes/no/i don't know)
*
Answer Required
Please describe the incident that occurred. Be as specific and accurate as possible. *
*
Answer Required
Your name / grade (optional)
Answer Required
Confirmation Email
Confirmation Email
Email Required
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