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: ______

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
Contact Information:
_____________________________________________________________________________

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

Was there a real or perceived imbalance of power? [ ] Yes [ ] No

Details: _______________________________________________________________________
_____________________________________________________________________________

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

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Signature: ________________________________ Date: _____________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - For Office Use Only- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Received By: _________________________________________ Date: ___________________

Position/Title: _________________________________________________________________

Date submitted to designated administrator for investigation: _____________________________

Adopted: May 11, 2020
Revised: March 28, 2022