ASD Tip Line
Directions: Please feel free to provide any information regarding ASD safety situations. The Arkansas School for the Deaf is committed to providing a safe environment to all members of our community. If you wish to report a disturbing incident involving students, please complete this form. Contact the school administrator for additional information or assistance at any time. This form can be completed anonymously. However, it will be easier for the school to investigate this matter if as much information as possible is provided. Every reported act of bullying will be investigated. Parents of aggressors and targets will be contacted in cases of confirmed bullying.

**If you are ASD Staff you must complete a Student Behavior Form.**

Date of Report (Today's Date): *
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Date of incident: *
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Name of student target: *
Your answer
Name of the alleged aggressor(s): *
Your answer
List of witnesses to the incident including staff members, students, or others: *
Your answer
Location of incident: *
Please describe the location of the incident as best you can. For example, "We were walking from the cafeteria to high school after dinner." *
Your answer
Time when incident occurred: *
Time
:
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used). *
Your answer
Did a physical injury result from this incident? *
Required
Please list prior incidents indicating a pattern of behavior that could constitute alleged bullying. Please include a description of the incidents, time, date, location and people involved. *
Your answer
Reporter's Name:
Your answer
Telephone/VP/Text Number:
Your answer
Email:
Your answer
Please check the appropriate box: *
Required
**If you are ASD Staff, you must complete a Student Behavior Form (SWIS).
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