JICK-E1 (FORM) Reporting Form

CAPE ELIZABETH SCHOOL DEPARTMENT REPORTING FORM

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: ____________________________________________________