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ANONYMOUS REPORTING FORM
Striving for Your Safety and Security!
If you feel unsafe or know someone who feels unsafe report it here.
You don't have to tell us your name, we just want to make sure you stay safe!
Date it happened?
*
+
Time it happened?
*
🛈
How many times
has this happened?
*
This is the first
One other time
Once a week
Once a month
Every day
Have you reported
this to an adult?
*
Yes
No
Did you report this to a
teacher, counselor or other
school staff member
before
filling out this form?
*
Yes
No
Where did it happen?
*
In Class
In front of the building
In the bathroom
In the cafeteria
In the gym
In the hallway
In the locker room
In the parking lot
On the bus
On the field
Over the phone or voicemail
In an email
In a text
On Social Media
Other
If Other, please explain
(or name social media like Instagram, Facebook...)
*
Describe what happened with as many details as you can, include the names of others who saw this happen.
*
Who are you?
*
Rather not say
Student
Teacher
Staff Member
Parent
Volunteer
Other
If other, please describe who you are.
*
What is your name
(Optional, you don't have to tell us your name
).
If you'd like us to contact you, please provide your email or phone number.
Once you submit this report we will investigate this further and contact you if you have provided an email or phone number.
Thank you for taking time to share this important information as this helps us establish an anti-bullying environment for everyone.
Anonymous submissions are welcome.
Inappropriate submissions will be investigated.
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