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Adams 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 form below.
Only boxes within asterisks are required to be completed.
Name of student exhibiting bullying behavior
*
Teacher
*
Date Time
*
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 (optional)
Email (optional)
Telephone number (optional)
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