Iberia R-V Bullying/Threat Form
EMERGENCY REPORTING

If reporting a current, impending, or urgent threat of violence against the school or specific people at school, please contact the school (573-793-6818) immediately. If the school cannot be reached, call the Iberia Police Department (573-793-6124) or the Miller County Sheriff's Department (573-369-2341). Please report such things as soon as possible in that manner, as this form may not be viewed immediately.
Reporter (Person Filing the Report)
Name
Or - I prefer to remain anonymous. (The district will investigate all allegations of bullying and threats, but it is more difficult to follow up on anonymous reports.) *
Required
Address
Phone Number
E-Mail
Relationship to the student being bullied or threatened (affected student, parent/guardian, fellow student, community member, etc.)
Bullying frequently involves repeated behavior. If you have witnessed or have knowledge of more than one incident, please provide information on all incidents. Please feel free to enter multiple forms. When finished with one report, you may submit another response separately.
Did you witness this incident? *
If no, provide specific information as to how you found out about this incident:
Details of Incident
Date and time the incident took place: *
Where did the incident take place? (Be as specific as possible. For example, instead of "the middle school," specify "the sixth-grade boy's bathroom at the middle school.") *
Please provide as much of the following information as possible for each student who was the target of the bullying or threats: 1) Name of the Targeted Student, 2) Grade Level
Please provide as much of the following information as possible for each student who was engaging in the bullying or threatening behavior: 1) Name of Subject of Report, 2) Grade Level
List the names of others who witnessed or may have witnessed the incident:
Please describe the incident. (Include as much detail as possible. Do not "clean up" anything that was said or done. If inappropriate language or gestures were used, include the exact language and describe the exact gestures used.) *
Is there any other information you believe is relevant for the district to know when investigating the incident?
Once received, this information will be forwarded to the appropriate staff member(s) for further action.
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