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

Policy Date: 09/20/2022

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SAU #15
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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.


Home Address:___________________________________________

Work Address:____________________________________________

Home Telephone:___________________________________________

Work Telephone:____________________________________________

Date of Alleged Incident(s):______________________________________

Name of person who was bullied:___________________________________


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)__________________________

Copy of report forwarded to SAU #15: ______________________   Date__________________________________


Reviewed: September 20, 2022