1606 Brady St.
Davenport, IA
563-336-5000

Administrative Regulation 504.10B

STUDENTS

Bullying

Bullying /Harassment Incident Report Form Or Witness Statement

 

Name of Person Bullied or Harassed: _____________________________________________________________

 

Names of Alleged Bully(ies) or Harassers:

 

_________________________________                   __________________________________

 

_________________________________                   __________________________________

 

Where Did the Incident Happen?   Choose all that apply:

 

_____ Classroom                                ______ Restroom                                ______ Bus

_____ Cafeteria                                   ______ Gym                                         ______ To/From School

_____ Hallway                                     ______ Locker Room                          ______ School Sponsored Activity or

Event off School Property

Describe in detail exactly what happened:

 

Physical evidence related to the incident to include physical marks, email, websites, video/audio tapes, photos or other evidence:

 

Names of Witnesses:

 

______________________________________       _____________________________________

 

______________________________________       _____________________________________

 

Other Information:

 

I AGREE THAT ALL THE INFORMATION ON THIS FORM IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE:

 

____________________________________________         _____________________________

Signature of Victim                                                                              Date

 

____________________________________________         _____________________________

Signature of Staff                                                                                 Date

 

Person filling out form Name:___________________________

Relationship to person bullied:      Self_________  Parent ________ Witness ________

 

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