File:  JICDE*-E-1 - Bullying Report Form

Instructions:  This form is to be completed by the bullying target, witness, or any person with information about an incident of bullying.  Upon completion, this form should be turned in to an administrator, teacher, or any staff member with whom the complainant is comfortable. Reports may be made anonymously.

Date of report: ________________________

Name of person making the report (optional): _________________________________

Check one:         [   ] Student         [   ] Parent/Guardian         [   ] Staff

                             [   ] Other (please specify):________________________________

If a student, specify school and grade (optional): _________________________

If a parent/guardian or other, provide contact information: __________________

Check if you prefer to remain anonymous: [   ] Yes         [   ] No

Are you the target of the alleged bullying?  [   ] Yes         [   ] No

Student(s) believed to be targets of alleged bullying (use reverse side if needed):

Name: ______________________________ School:_____________ Grade:_______
Name: ______________________________ School:_____________ Grade:_______
Name: ______________________________ School:_____________ Grade: _______

Person(s) believed to be engaged in alleged bullying conduct (use reverse side if needed):

Name: ______________________________ School:_____________ Grade:_______
Name: ______________________________ School:_____________ Grade:_______
Name: ______________________________ School:_____________ Grade:_______

Person(s) believed to have witnessed or have knowledge about the alleged bullying (use reverse side if needed):

Name:______________________________ School:_____________ Grade:_______
Name:______________________________ School:_____________ Grade:_______
Name:______________________________ School:_____________ Grade:_______
Name:______________________________ School:_____________ Grade:_______

Date(s), time(s), and location(s) of the alleged bullying incident(s) (use reverse side and/or additional pages if needed): ___________________________________________________________________
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Description of the alleged bullying incident(s), including any incident-related evidence (use reverse side and/or additional pages if needed):____________________________

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By completing and signing this form, I attest that the information provided, including any attached incident-related evidence, is true and accurate to the best of my knowledge.

Signature:_______________________________________ Date: _________________

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For Office Use Only

Received By: ____________________________________ Date: _________________

Position/Title: ____________________________________ Date: _________________

Date submitted to designated administrator for investigation: _____________________

Issued:  May 18, 2020