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Bullying Referral Form
A person is bullied when he or she is exposed, repeatedly over time, to negative actions on the part of one or more other persons, and he or she has difficulty defending himself or herself.
If you would like to make a bullying incident referral, please complete the below form.
Only boxes with an * are required to be completed.
Name of student exhibiting bullying behavior.
*
Teacher
*
Date
*
MM
/
DD
/
YYYY
Location of Incident
Victim
*
Bullying Behavior Observed
*
Saying hurtful, unpleasant, mean, or using ugly nicknames
Excluding a child from an activity deliberately
Physical Aggression ie. hitting, pushing, slapping
Telling lies, spreading rumors,
Any additional information you would like to share.
Person Making Referral
*
Email
*
Phone Number
*
mhtyler@henrico.k12.va.us
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