JICK-R1 - Bullying Report Form

ACTON SCHOOL DEPARTMENT BULLYING REPORT FORM

Date the alleged bullying incident(s) is reported:  _____

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

Status of reporter:  Student    Parent    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):  ___________________________

Names 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.

_____________________________________          Date:  _____________ 

Signature of complainant/reporter     

Received by:  _________________________   Date:  _____________

Position/title:  _________________________ 

Copy to building Principal: Date:  ___________________________________ 

Copy to Superintendent (if different):  Date: ___________________________

ACTON SCHOOL DEPARTMENT