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: ____________________________________________________