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TMHS - Bully Reporting

TOURTELLOTTE MEMORIAL HIGH SCHOOL

Report of Suspected Bullying Behaviors

Name of Person Completing Report:*

Answer Required

Date:*

Answer Required

Target(s) of Behaviors:*

Victim(s)

Answer Required

Report Filed Against:*

Answer Required

Date of Incident(s):*

Answer Required

Location(s):*

Answer Required

Time:*

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Type of Bullying*

Answer Required

Verbal

Non-verbal

Physical

Cyber-bullying

Other:

Describe the basis for your report. Include Information about the incident, participants, background tot he incident, and any attempts you have made to resolve the problem. Please note relevant dates, times, and places.

Briefly describe the incident:*

Answer Required

Indicate if there are witnesses who can provide more information regarding your report. If the witnesses are not school district staff or students, please provide contact information:

Name/Phone#/Address

Answer Required

Please provide an email address if you would like to receive a confirmation email regarding your report.

Confirmation Email

Email Required