File: JICDE*-E-1 - Bullying Report Form File: JICDE*-E-1 - Bullying Report FormNOTE: While Colorado school districts are not required by law to adopt an exhibit on this subject, CASB believes this sample contains the content/language that reflects "best practices." However, the district should consult with its own legal counsel to determine appropriate language that meets local circumstances and needs.
Instructions: Bullying is reportable in person or in writing to school staff. 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): ________________________
Contact information of person reporting (optional):
Phone: ________________________ Email: ______________________________
Check if you prefer to 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: ____________________________________ [ ] Student [ ] Staff [ ] Other
Name: ____________________________________ [ ] Student [ ] Staff [ ] Other
Name: ____________________________________ [ ] Student [ ] Staff [ ] Other
Person(s) believed to have witnessed or have knowledge about the alleged bullying (use reverse side if needed):
Name: ____________________________________ [ ] Student [ ] Staff [ ] Other
Contact information: __________________________________________________________________
Name: ____________________________________ [ ] Student [ ] Staff [ ] Other
Contact information: __________________________________________________________________
Name: ____________________________________ [ ] Student [ ] Staff [ ] Other
Contact information: __________________________________________________________________
Name: ____________________________________ [ ] Student [ ] Staff [ ] Other
Contact information: __________________________________________________________________
Date(s), time(s), and locations(s) of the alleged bullying incident(s) (use reverse side and/or additional pages if needed): ____________________________________
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Was there a real or perceived imbalance of power? [ ] Yes [ ] No
Details:
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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: ____________
______________________________________________________________________For Office Use Only
Received By: ______________________________________ Date: ___________
Position/Title: _______________________________________________________
Date submitted to designated administrator for investigation: __________________
(Issue date)
[Revised February 2022]
COLORADO SAMPLE EXHIBIT 2020©