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PAINT ROCK

INDEPENDENT SCHOOL DISTRICT INDEPENDENT SCHOOL DISTRICT

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Report a Student Health/Safety or Bullying Incident

Please complete this form to the best of your knowledge so we can assist you.
This information will be kept confidential with your campus administrator and/or superintendent.

Please Fill Out The Report a Student Health/Safety or Bullying Incident Below

Date of Incident:

Date of Report:

Who was the person(s) engaged in incident?
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Grade of person(s) who engaged in incident?
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Who was the recipient of the incident?
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Grade of the recipient in incident?
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What type of incident?

Physical

Emotional/Social

Damage to Property

Online

Where did the incident take place?

After School Program

Bus

Bus Stop

Cell Phone

Classroom

Hallway

Gym

Internet

Locker Room

Lunch Room

Parking Lot

Playground

Restroom

School Sponsored Event

Other:
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Other location details: (Please explain the specific location details such as which hallway, where on the Internet, what restroom, etc)

Describe what happened with as many details as possible.

Person reporting the incident:(OPTIONAL). Please use your full name.
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May we contact you for more information on this incident?

Yes

No

Thank you for reporting this incident. We appreciate your concern. When you click "Submit Form" this will be sent to the campus administrator.

Email a copy to

optional

Required Fields

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