Incident Date 

Incident Time

Name

Phone

Address

Who Committed these act(s) against you

Witnesses to the incident(s)

Were you:  

Kicked  yes  no

Shoved  yes  no

Struck  yes  no

Threatened  yes  no

Explain any pertinent details below:

Has the person engaged in these activities repeatedly?  yes  no

If so, please explain in the box below where, when, and what happened.

Has the person teased or taunted you in any way?  yes  no

If so, please explain in the box below.

Notice:  False Reports- A person, who knowingly gives false information to any person of authority with the intent to implicate another of harassment, will incur discipline equal to the false allegation.