Rosebud-LottIndependent School District

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HS BULLYING INCIDENT REPORT FORM

Repeat Infraction?*
Answer Required
Location of Incident (check all that apply)*
Answer Required

Name of Victim(s)

Name of Student(s) Bullying

Name(s) of Witnesses/Bystanders

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