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Harassment and/or Bullying Complaint Form
Today's Date
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Name of Person Reporting Incident
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Email of Person Reporting Incident
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Mobile Phone of Person Reporting Incident
Student Name
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Grade
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K
1
2
3
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5
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10
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12
Date of Incident
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School
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Albany Avenue Elementary School
Alleghany Avenue Elementary School
Daniel Street Elementary School
Harding Avenue Elementary School
West Gates Elementary School
William Rall Elementary School
Lindenhurst Middle School
Lindenhurst High School
Lindenhurst Academy
Details of Incident
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Names of the Individuals Accused of Bullying and/or Harassment
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Names of Witness (if available)