| Name Of the Person Reporting Bullying * |
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| Alleged Bully * |
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| Target (persons being bullied) * |
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| When did the incident happen? * |
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| What type of bullying? * |
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| Incidents/Events * |
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| Where did the events take place? * |
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| List anyone else who may have heard or seen the incident * |
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| How long has this been happening? * |
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| Is the event repeating? |
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