AR 411.1 Exhibit A – Student Harassment Complaint Form
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
By whom Date