* 1. What is the name of the Bully?

* 2. What grade is the bully in?

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

* 4. On what day did the bullying occur?

* 5. What location did the bullying occur?

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

* 7. Describe what happen?

* 8. Anymore information you would like to share?

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

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