FORM - JICK-E1

CAPE ELIZABETH SCHOOL DEPARTMENT REPORTING FORM

[PrintablePDF version of Form JICK-E1.pdf]

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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: ____________________________________________________