JICK-E1 (FORM) Reporting Form

CAPE ELIZABETH SCHOOL DEPARTMENT 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: ____________________________________________________