Name:
Grade:
5
6
7
8
Date Incident Occurred:
-
Month
-
Day
Year
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Location of Incident:
Classroom
Hallway
Lunchroom
Recess
Bus
Other
Type of Incident:
Verbal
Physical
Emotional
Exclusion
Cyber
Have you reported the incident to an adult?
Yes
No
Your role in the incident:
Victim
Witness
Has this type of incident happened before?
Yes
No
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