Jack Dailey Elementary School

Report Form

Please take a moment to fill out the report form below completely as possible and send it to us. Jack Dailey ES does not tolerate bullying or harassment and your report will be followed up promptly.

VICTIM'S NAME: Name: Student Number: Grade: --------------------------------------------------------------------------------------------------------- PARENT'S NAME (Optional--- helpful if you want to be contacted) Last Name: First Name: Contact Number: - - Home: Cell: Work: EMAIL ADDRESS: --------------------------------------------------------------------------------------------------------- DESCRIPTION OF INCIDENT(S): Please specify the name(s) of the person(s) who are bothering you, including what they are doing, where it occurs and when it happened.