JICDE-E-1, Bullying Report Form
JICDE-E-1, Bullying Report Form
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: __________
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
Name: ___________ [ ] Student [ ] Staff [ ] Other
Name: ___________ [ ] Student [ ] Staff [ ] Other
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: __________
For Office Use Only
Received By: __________ Date: __________
Position/Title: __________
Date submitted to designated administrator for investigation: __________
(February 17, 2021)