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

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: __________________

Issued October 2, 2001

Revised August 21, 2023