For access to the form, click here.
Policy JICK-E1
Bullying Report Form
Date the alleged bullying incident (s) is reported: ____________
Name of person investigating alleged incident(s): _________________________
Position/title of investigator: __________________________________________
Name of complainant/person reporting bullying (by law, reports may be anonymous): _________________________
Complainant/reporter is (circle one): Student Parent School employee Coach/advisor Volunteer Other ________
Name(s) of alleged target(s): ___________________________________________
Name(s) of alleged bully(ies): ___________________________________________ Relationship between alleged target(s)/bully(ies): ___________________________
Date(s), time(S) and location(s) of the alleged incident(s):______________________
Name(s) of potential witnesses: ___________________________________________
Description of incident(s), including any supporting documentation (use additional pages if more space is needed):
I agree that the information on this form is accurate and true to the best of my knowledge and belief.
__________________________________________ ______________
Signature of complainant/reporter Date
Received by:____________________________________________
Position/title:____________________________________________
Copy to building principal: Date:_____________________
Copy to Superintendent: Date:_______________________
12/28/16
*Please excuse any formatting errors.
