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
Your answer
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
Your answer
Phone Number
Your answer
Email
Your answer
Relationship to the student being bullied or threatened (affected student, parent/guardian, fellow student, community member, etc.)
Your answer
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:
Your answer
Details of Incident
Date and time the incident took place: *
Your answer
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.") *
Your answer
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
Your answer
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
Your answer
List the names of others who witnessed or may have witnessed the incident:
Your answer
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.) *
Your answer
Is there any other information you believe is relevant for the district to know when investigating the incident?
Your answer
Once received, this information will be forwarded to the appropriate staff member(s) for further action.
Submit
Never submit passwords through Google Forms.
This form was created inside of Iberia R-V School. Report Abuse - Terms of Service - Additional Terms