Rosebud-LottIndependent School District

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RPS BULLYING INCIDENT REPORT FORM
Repeat Infraction?*
Location of Incident (check all that apply)*

Name of Victim(s)

Name of Student(s) Bullying

Name(s) of Witnesses/Bystanders

Type of Bullying*
Bullying Behaviors (check all that apply)*
Cyber-Bullying used*
Result in Injury*
Reported to School Nurse?*
Reported to Police?*
Reported to School by (check all that apply)*
Physical Evidence?*
Confirmation Email