EXHIBIT A – STUDENT HARASSMENT / BULLYING REPORT FORM

(Administrative Rule 411.1)

Name of person providing information for the form                                                                                       

Name of person completing form                                                                   Date                                      

Signature ________________________________________                     Date_________________   

Where did or is the incident(s) occur(ring) (building, grounds)?                                                                      

When did or is the incident(s) occur(ring)? Date                                          Time                                        

Was or is anyone else present at the time the incident(s) occurred or is occurring?                                         

Who was or is involved in the incident(s)?                                                                                                    

What happened or is happening (nature of complaint)?                                                                                  

How does individual(s) want the incident(s) resolved? (Optional)                                                                   

                                                                                                                                                                  R 411.1 - Student Harassment / Bullying Report Form

Action taken:

                 By whom                                                                                   Date