Reporting Form - JICK-E1
Bullying and Cyberbullying Reporting Form
Bullying or suspected bullying is reportable in person or in writing (including anonymously) to school personnel.
Date (of the alleged incident of bullying is being reported):
10/15/2024
Person's name reporting the alleged
incident(s) of bullying, IF not anonymous.
Your Role
Are you a
student
parent
grandparent
guardian
school staff
coach
advisor
other
Cell Phone
Work Phone
Email Address
Address
Person's Name completing this form IF different
from above, and not anonymously reporting.
Your Role
Are you a
student
parent
grandparent
guardian
school staff
coach
advisor
other
Cell Phone
Work Phone
Email Address
Address
Details
Student Name
(of who is believed to have been bullied)
Student's Name
Required
Student's School
Required
** Please Select **
Windham High School
Windham Midle School
Jordan Small Middle School
Manchester Elementary School
Raymond Elementary School
Windham Primary School
Student or Adult Name(s)
(of who is alleged to have bullied)
Alleged Aggressor 1
Required
Alleged Aggressor 1 School
Required
** Please Select **
Windham High School
Windham Middle School
Jordan Small Middle School
Manchester Elementary School
Raymond Elementary School
Windham Primary School
Not A Student In RSU #14
Alleged Aggressor 2
Alleged Aggressor 2 School
** Please Select **
Windham High School
Windham Middle School
Jordan Small Middle School
Manchester Elementary School
Raymond Elementary School
Windham Primary School
Not A Student In RSU #14
Incident(s) Information
Date(s)
Required
Time(s) of Day
Incident Location(s)
Required
Provide a description below of incident(s)
Required
Were there Witnesses?
Yes Or No
Yes
No
Required
I agree the information provided is accurate and true to the best of my knowledge and belief.
Signature (optional, type your name)
Sign Date
Submit Bullying Report
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