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Bullying Report Form

CODE: JICK - E1

Maine School Administrative District No. 31

MSAD #31 BULLYING REPORT FORM

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): __________________________________

Time(s) and location(s) of alleged incident(s):  __________________________________

Names of witnesses: _______________________________________________________

Description of incident(s) (attached 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:  Date: _________

First Reading:      01/03/2013
Second Reading: 01/16/2013