JICK-E1 - Bullying Report Form

JICK-E1 - MSAD # 35 - Bullying Report Form

Date the alleged bullying incident(s) is reported:  

Name of complainant/reporter (by law, reports may be anonymous): __________________________________________________________________________ 

Status of reporter:  Student    Parent    School (employee/coach/advisor)    Other
__________________________________________________________________________

Contact information for reporter (if reporter is student, contact information for parent/guardian):

Phone: _________________ Cell phone: __________Email: ____________ 

Address: ___________________________________________________________________

Name of alleged target(s): _____________________________________________________ 

Name of alleged bully(ies): _____________________________________________________

Relationship between alleged target/bully(ies): _____________________________________

Date(s), time(s) and location(s) of alleged incident(s): _______________________________

Names of 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.

______________________________________________  Date: _____________

Signature of complainant/reporter                                                   

Received by: ___________________________________ Date: _____________

Position/title: ___________________________________

Copy to building principal: Date: ___________________________________     

Copy to Superintendent: Date: _____________________________________

Cross Reference: ACAA-R – Student Harassment and Sexual Harassment Procedure

JICK – Bullying

JICK-R - Bullying-Administrative Procedure

JRA-R – Student Education Records and Student Information

 

Policy Adopted: November 1, 2006

Policy Revised: May 15, 2013, March 01, 2017

Policy/Exhibit Reviewed: January 20, 2021