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 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: ____

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

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

Date(s), time(s), and locations(s) of the alleged bullying incident(s) (use reverse side and/or additional pages if needed): ____________________________________

_________________________________________________________________

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

_________________________________________________________________

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 submitted to designated administrator for investigation: __________________

Issued: March 10, 2020