Skip to main content

JICK-E2 - Bullying Investigation And Response Form

JICK-E2 - MSAD #35 - Bullying Investigation And Response Form

Date the alleged incident of bullying was reported: ____________________________

Name of person investigating alleged incident(s): _____________________________

Position/title of investigator: ______________________________________________

Name of person reporting bullying incident(s): _______________________________

Person reporting is (circle one) Student          Parent          School Employee          Coach/advisor          Volunteer

Other ________________________________________________________

Name(s) of alleged target: _________________________________________________

Name(s) of alleged bully (bullies): __________________________________________

Name(s) of potential witnesses: _____________________________________________ 

Where did the alleged incident(s) occur (check one or more):

        _____ on school property

        _____ on school bus

        _____ at a school sponsored activity

        _____ through use of technology      ___ at school ___ off-campus

        _____ elsewhere (be specific)

Time and location(s) of incident(s):

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does targeted student have an IEP?  ____ Yes ____ No (If yes, refer to plan.)

Does targeted student have a 504 plan?  ____ Yes ____ No (If yes, refer to plan.)

Is the targeted student in the referral process for either?  ____ Yes ____ No

(If yes, specify) _________________

If the targeted student receives special services, when were Special Services Director and/or 504 Coordinator notified of the incident:

Person notified:  __________________________ Date: ____________________

Does alleged bully have an IEP?  ____ Yes ____ No (If yes, refer to plan.) 

Does alleged bully have a 504 plan?  ____ Yes ____ No (If yes, refer to plan.)

Is the alleged bully in the referral process for either?  ____ Yes ____ No

(If yes, specify) _________________

If the alleged bully receives special services, when were Special Services Director and/or 504 Coordinator notified of the incident:

Person notified: _____________________________________ Date: ___________________

Do school unit’s records show prior reports of alleged or substantiated incidents of bullying involving the alleged target or alleged bully?  If so, describe incident and outcome(s):

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Meeting/interview of student who believes he/she has been bullied, description of alleged incident(s) (dates and details):

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Communications with parents(s) of student who believes he/she has been bullied date(s) and details): 

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Meeting/interview of alleged bully (bullies) (dates and details):

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Communications with parent(s) of alleged bully (bullies) (dates and details):

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Meeting/interview of persons identified as witnesses (dates and summary of information provided):

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Further evidence of bullying examined (videos, photos, email, letters, etc.):

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Measures taken pending conclusion of the investigation to ensure the safety of the student who believes he/she has been bullied:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Safety measures communicated to parents of student who believes he/she has been bullied (date and details):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is the alleged bullying substantiated, i.e., does the alleged conduct meet the definition of bullying as articulated in Board policy?  ____Yes ____No

Nature of harm incurred:

        ____Physical harm to student or damage to student’s property

        ____Student’s reasonable fear of physical harm or damage to property

        ____Hostile educational environment

        ____Infringement of student’s rights at school

Conduct resulting in harm (in item above) is on the basis of:

        ____National origin/ancestry/ethnicity

        ____Religion

        ____Physical, mental, emotional or learning disability

        ____Sex

        ____Sexual orientation

        ____Gender/gender identity/expression

        ____Age

        ____Socioeconomic status

        ____Family status

        ____Physical appearance

        ____Weight

        ____Other distinguishing personal characteristics

        ____Other (explain) _______________________

Summary of investigation/Explanation of findings: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Disciplinary action - alternative discipline: ___________________________________

Disciplinary action – suspension (in-school, out-of-school): ______________________

Expulsion (recommended for expulsion): _____________________________________

Recommendations for support services:     

Counseling/referral to services (targeted student): _______________________________

Counseling/referral to services (bully): _____________________­­­­­_____________­­______

Recommendation to report to law enforcement?  ____ Yes ____ No

____ Potential criminal violation         ____ Potential civil rights violation

Recommendations in other substantiated bullying situations: 

If bully is school employee or administrator, recommendation for action to be taken by Superintendent (any action must be consistent with collective bargaining agreement or individual contract):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If bullying is by another adult person associated with the school (e.g., volunteer, visitor, or contractor):

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If bullying involves a school-affiliated organization: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature of investigator: _________________________________________________

If investigator is not building principal, copy to principal on [date]                

Copy to Superintendent on [date]

ACTIONS TAKEN BY PRINCIPAL

The student received/will receive the following discipline actions (consequences):

_____ Alternative Discipline

_____ Detention

_____ Weekend Detention

_____ In-school suspension

_____ Out-of-school suspension

_____ Expulsion/Recommended for expulsion

Alternative discipline imposed for this student (if applicable):

_____ Meeting with the student and the student's parent(s) or guardian(s)

_____ Reflective activities, such as requiring the student to write an essay about the student's misbehavior

_____ Mediation, but only when there is mutual conflict between peers, rather than one-way negative behavior, and both parties voluntarily choose this option

_____ Counseling

_____ Anger management

_____ Health counseling or intervention

_____ Mental health counseling

_____ Participation in skills building and resolution activities, such as social/ emotional/ cognitive skills building, resolution circles and restorative conferencing

_____ Community service

Referral to law enforcement?  ____ Yes ____ No

Written notice has been provided to parent(s)/guardian(s) of the student who has been found to have engaged in bullying, including the process for appeal.

Notification sent by principal: [Date]

Copy to Superintendent: [Date]


APPEAL OF PRINCIPAL’S DECISION

Date appeal submitted: ________________________________________________________

All appeals to the Superintendent must be submitted, in writing, to the Central Office within 14 calendar days of the building principal’s decision. The Superintendent’s decision shall be final.

Superintendent’s decision: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Date parent(s)/guardian(s) notified of Superintendent’s decision: ______________________  

ACTIONS TAKEN BY THE SUPERINTENDENT

____Recommendation to Board for student expulsion

____Action on student/parent appeal of principal’s decision ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____Action taken against employee: (If confidential employment action, in personnel file) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____Recommendation to Board for suspension/revocation of sanctioning/approval of school-affiliated organization

____Other:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

      


Cross Reference: ACAA-R – Student Harassment and Sexual Harassment Procedure

JICK – Bullying

JICK-R - Bullying-Administrative Procedure

JRA-R – Student Education Records and Student Information

 

Policy Adopted: November 1, 2006 

Policy Revised: May 15, 2013, March 01, 2017

Policy/Exhibit Reviewed January 20, 2021

Back to top