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Report Bullying and Help Stop Bullying
Bullying Report Form
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Email Address
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Name
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Last Name
What kind of bullying? (Check all that apply.)
Physical
Verbal
Indirect
Social Alienation
Group Bullying
Intimidation
Cyberbullying
How many times?
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1 time
Once a Day
More than Once a Day
Once a Week
More than Once a Week
Once a Month
More than Once a Month
Once a Year
More than Once a Year
Age of Child
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Under 5
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Over 18
School Grade
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Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
Other
Reported to School?
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No
Yes
Did the School Resolve Bullying Incident(s)?
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No
Yes
School Name
School District
County
State
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Alaska
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District of Columbia
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Texas
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Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other (Outside US)
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