JICK-E2 Bullying Investigation and Response Form
- Brett Saucier
- 16 hours ago
- 4 min read
NEPN/NSBA Code: JICK-E2
MSAD #60 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 the alleged bully have an IEP? ____ Yes ____ No (If yes, refer to plan.)
Does the 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: ________________________________Date_____________
If investigator is not building administrator, copy to building administration
Copy to Superintendent on:__________
ACTIONS TAKEN BY SCHOOL ADMINISTRATION
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 school administration: 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 10 business days of the building administration’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 school administration’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: _____________________________________________________________
_______________________________________________________________________
Adopted 5.21.26