What is the name of the Bully?

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* 1. What is the name of the Bully?

What grade is the bully in?

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* 2. What grade is the bully in?

What is the victims name? (Optional)

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* 3. What is the victims name? (Optional)

On what day did the bullying occur?

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* 4. On what day did the bullying occur?

What location did the bullying occur?

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* 5. What location did the bullying occur?

Were there any witnesses?  If so, please give name(s).

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* 6. Were there any witnesses?  If so, please give name(s).

Describe what happen?

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* 7. Describe what happen?

Anymore information you would like to share?

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* 8. Anymore information you would like to share?

Have you told an adult about the incident?  If so, who did you tell?

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* 9. Have you told an adult about the incident?  If so, who did you tell?

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