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Lemoore Union HSD |  E  5131.2  Students

Bullying   

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Bullying Report

To: School Site Principal

From: Name: _______________________________________________________

Address: ____________________________________________________________

Phone Number(s): ____________________________________________________

Name of Person(s) against whom report is made:

___________________________________________________________________

Nature of Report: In your own words, please describe the incident(s) that occurred. Please include all names, dates, and places necessary for a complete understanding of the incident(s).

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

(You may attach additional paper as necessary)

Have you discussed this incident(s) with anyone else?________________________

If so, please list those you have spoken to:

____________________________________________________________________

____________________________________________________________________

Were there witnesses to the incident(s)? ____________________________________

If so, please list those who were witnesses:

_____________________________________________________________________

I/We understand that the Superintendent or designee may request further information about this complaint and as such information is available, I/We will provide it upon request.

I/We certify under penalty of perjury that the above documentation is true and correct.

Executed this _________day of _____________, 20_____ at ____________________

Signature: _____________________________________________________________

Exhibit LEMOORE UNION HIGH SCHOOL DISTRICT

version: August 27, 2015 Lemoore, California