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: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Recommended disposition:   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