Policy JICK-E1
Any student, school employee, designated volunteer, employee, community member, parent or visitor to the campus who has witnessed, received a report of, or has information that a school community member has been subject to bullying, cyberbullying, harassment, sexual harassment or retaliation shall report such incident to the appropriate school or facility Administrator or designee as soon as possible after observing the incident or receiving the information. Reporting parties unable to report in writing will be provided a scribe to assist in the reporting process.
DEFINITION OF BULLYING, CYBERBULLYING, HARASSMENT AND RETALIATION
1. Name of Person Filing the Incident Report
(Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report).

First Name:   Last Name:  
2. Check whether you are the:      
3. Check whether you are a:            

Your contact information/telephone number:  
4. If student, state your school:        Grade:  
5. If staff member, state your school or work site:  
6. Information about the incident:
Governing School where incident/s took place: (required)  
 
Name(s) of Target(s):          
Name(s) of Aggressor(s):    
Date(s) of Incident(s):         
Time(s) When Incident(s) Occured:  
SPECIFIC Location(s) of incident(s):  
If Cyberbullying, what is the point of origin:  
7. Witnesses (List people who saw the incident or have information about it.):
Name:           
Name:           
Name:           
Name:           
Name:           
Name:           
8. Describe the details of the incident (including names of people involved, what occured, and what each person did and said, including specific words used).

 
9. Digital Signature of Person Filing this Report: (Type name and last 4 of ssn or staff/student ID to sign):

 

Date:
 
(Note: Reports may be filed anonymously).

10. On Submission this form is sent to the Governing School's Affirmative Action Officer.
                                                                  
Submit Incident Form
           
 
 
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