MSAD 52 Bullying Reporting Form
This form is based on policy JICK-E1
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Reporter Section
Please complete this form until you get to the Administrator section, then hit the Submit button
Date the alleged bullying incident(s) is reported *
MM
/
DD
/
YYYY
Name of the complainant/reporter
By law, reports may be anonymous
Status of reporter *
Contact information for reporter - phone
If reporter is a student, contact information for parent/guardian
Contact information for reporter - email
If reporter is a student, contact information for parent/guardian
Contact information for reporter - address
If reporter is a student, contact information for parent/guardian
Name of alleged target(s) *
Building of alleged target(s) *
This will determine which administrator will receive this report, so please select carefully
Name of alleged bully(ies) *
Relationship between alleged target/bully *
Date of alleged incident
MM
/
DD
/
YYYY
Time of alleged incident
Time
:
Location of alleged incident
Names of witnesses
Description of incident(s) *
I agree that the information on this form is accurate and true to the best of my knowledge and belief
Type your name to sign this agreement.  This is optional if you wish to remain anonymous.
Administrator Section
The administrator who receives this allegation should acknowledge the receipt here.  This is not signifying an investigation has been completed, just that this has been received.
Received by
Please enter your name and building, as well as position here
Received date
Please enter the date you are acknowledging receipt of this report
MM
/
DD
/
YYYY
Submit
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