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Bullying Report Form

Maine School Administrative District No. 31

MSAD #31 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 Date: _________


First Reading: 01/03/2013

Second Reading/Adoption: 01/16/2013

Amendment First Reading: 03/29/2017

Second Reading/Adoption: 04/12/2017