Policies » Section J: Students » JICK-R: Bullying Report Form

Policy Date: 09/20/2022

SAU #15
AUBURN CANDIA HOOKSETT
Please circle one above

BULLYING REPORT FORM

General Statement of Policy Prohibiting Bullying
Bullying is conduct which subjects a pupil to insults, taunts, or challenges, whether verbal or physical in nature, which are likely to intimidate or provoke a violent or disorderly response from the student being treated in this matter.

Complainant/Witness/Reporter:_______________________________

Home Address:___________________________________________

Work Address:____________________________________________

Home Telephone:___________________________________________

Work Telephone:____________________________________________

Date of Alleged Incident(s):______________________________________

Name of person who was bullied:___________________________________

Aggressor:__________________________________________________

Were there any prior incidents regarding the same parties? If so, briefly describe action taken.

__________________________________________________________________

List any witnesses that were present:_________________________________________

Where did the incident(s) occur?:___________________________________________

Describe the incident(s) as clearly as possible, including such things as: what force, if any was used; any
verbal statements (i.e., threats, requests, demands, etc.); what, if any, physical contact was involved
(Attach additional pages if necessary):_________________________________________________

_____________________________________________________________________________

Date reported to parents:___________________________________

Disposition of the incident or action taken:_________________________________________

Received by (Principal or designee)__________________________

Date________________________________
Copy of report forwarded to SAU #15: ______________________   Date__________________________________

Reviewed: September 20, 2022