- Section J: Students
JICK -E1 -REPORT FORM FOR ALLEGED BULLYING
Date the alleged bullying incident(s) is reported: _______________
Name of complainant/reporter (by law, reports may be anonymous): ________________
Status of reporter: Student Parent School employee/coach/advisor Other _________
Contact information for reporter (if reporter is student, contact information for parent/guardian):
Phone: ________ Cell phone: ________ Email: ________________
Address: ________________________________________________
Name of alleged person targeted: __________________________________________________
Name of alleged bully(ies): _________________________________________________
Relationship between alleged target/bully(ies): __________________________________
Date(s), time(s) and location(s) of alleged incident(s): ___________________________
Names of witnesses: _______________________________________________________
Description of incident(s), including any supporting documentation (use additional pages if more space is needed):
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I agree that the information on this form is accurate and true to the best of my knowledge and belief.
_____________________________________ Date: _____________
Signature of complainant/reporter
Received by: _________________________ Date: _____________
Position/title: _________________________
Copy to building principal: Date: ___________________________________
Copy to Superintendent: Date: _____________________________________
- Section J