(INTERNET VERSION)

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* 1. DATE AND TIME THAT YOU EXPERIENCED BUTTHURT:

Date
Time

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* 3. PLEASE TELL US MORE ABOUT THE INCIDENT OF BUTTHURT.

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* 4. PLEASE TELL US MORE ABOUT THE PERSON WHO CAUSED THE BUTTHURT.

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* 5. DID YOU TAKE ANY ACTIONS YOURSELF REGARDING THE BUTTHURT?

T