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Thursday, May 17, 2012
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1. Contact Information (Optional - you may skip to step 2)
Last Name: First Name: Telephone: School I attend (if applicable): E-Mail Address:
2. Victim type:
Crime is against a Student Staff Member
3. Specific Type
Assault Gang Activity Drugs Abuse/Bullying Harassment Weapon in School (Specify) Gun Knife Other Other (Specify)
4. Date and Location of Incident
This event will occur in the future occurred in the past Date: Time: School: Location in School: 5. Who was involved :
Suspect: Victim:
6. Please provide a short description of the incident:
7. May we contact you for additional information?
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