Report Bullying* indicates required fieldsToday’s Date: MM slash DD slash YYYY Your Name: First Last Grade*Pre-KKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thStudent(s) who participated in bullying behavior:Name(s):Grade(s):Student(s) who was bullied:Name(s):Grade(s):Did anyone else witness this situation?Name(s):About the IncidentPlease choose one of the options below: "I was bullied." "I saw someone get bullied."Date of Incident: MM slash DD slash YYYY Where the bullying happened: Classroom Hallway Bathroom Cafeteria Outside Text/Social Media/Internet Bus Locker Room/Gym OtherIf other, explain where the incident occurred:When the bullying happened: Before School After School During Class Hallway Lunchtime OtherIf other, explain when the incident occurred:What happened: “I was...” or “I saw someone get...”Verbally Bullied Teased Called Names ThreatenedPhysically Bullied Shoved Hit Tripped Kicked Damaged PropertySocially Bullied Rumor Spreading Social Isolation Excluded PurposefullyCyber Bullied Derogatory Comments or Posts Spreading Rumors ThreatenedPlease add any other information about the incident that would be helpful for PCA counselors or administration to know about this situation.How would you like to be contacted regarding this situation? Email Phone During School Before School After SchoolIf you would like to be contacted during school, which period would be preferable?
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