Bullying/Harassment Incident Reporting Form (JICK-E)
Please fill out the following form with as much detail as possible. Having information from the reporting person is very helpful for any follow up questions we might have, but those sections are not a requirement and may be left blank.
Nature of alleged incident: *
Your answer
Date the alleged incident is being reported: *
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DD
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YYYY
Date the alleged incident occurred: *
MM
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DD
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YYYY
Time the alleged incident occurred: *
Time
:
Person(s) reporting the alleged incident:
Your answer
Reporting person(s) contact information (phone, email address):
Your answer
Name of alleged victim: *
Your answer
School attended by the victim: *
Name of alleged perpetrator: *
Your answer
Relationship of reporting person to student/alleged victim:
Your answer
Witness(es) of the incident: *
Your answer
Location of the incident: *
Your answer
Description of the incident: *
Your answer
I agree that this form is accurate and true to the best of my knowledge and belief. *
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