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* 1. Name (optional), Information, School, Date?

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* 2. Anonymous, Confidential or Non-Confidential?

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* 3. Targeted person, Bullies, Witnesses, Dates?

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* 4. Where Did the incident(s) happen? Choose all that apply.

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* 5. Please check the box that best describes what the bully did. Please choose all that apply.

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* 6. Why did you think the bullying occurred?

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* 7. Is there any additional information you would like to provide?

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