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JICK-E1 (FORM) Reporting Form


[PDF version of Form JICK-E1.pdf]

The information below is the complete form. Please use the link above to download a PDF version of the form

Date the alleged bullying incident(s) reported: ________________________________________


Name of complainant/reporter (by law, reports may be anonymous):_______________________


Status of reporter: Student Parent/Guardian 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 target(s): ________________________________________________________


Name of alleged bully(ies): _______________________________________________________


Relationship between alleged target/bully(ies): ________________________________________


Date(s), time(s) and location(s) of alleged incident(s): __________________________________


Name 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.

______________________________________ ______________________________

Signature of Complainant/Reporter Date


Received by: ___________________________ Date: _________________________


Position/title: ___________________________ Date: _________________________


Copy to Building Principal – Date: _________________________________________________


Copy to Superintendent – Date: ____________________________________________________