CODE: JICK - E2 Maine School Administrative District No. 31 MSAD #31 BULLYING INVESTIGATION FORM Date: ____________ 1. Name of person investigating alleged incident(s): _________________________ Position/title of investigator: __________________________________________ Name of complainant/person reporting bullying: _________________________ Name(s) of alleged target(s): ___________________________________________ Complainant/reporter is (circle one): Student Parent School employee Coach/advisor Volunteer Other ________ Name(s) of alleged bully(ies): __________________________________________ Name(s) of potential witnesses: _________________________________________ 2. Relationship between alleged target(s)/bully(ies): _________________________ 3. Did the alleged incident(s) occur (check one or more): _____ on school property (including a school bus) _____ at a school sponsored activity _____ through use of technology _____ elsewhere Time and location(s) of incident(s): ______________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 4. Is this a first time occurrence or has the same or similar occurred previously? ___________________________ 5. Interview of complainant/reporter’s, description of alleged incident(s): _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 6. Interview of alleged bully(ies): __________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 7. Name(s) of potential witnesses, if any: _________________________________ 8. Witnesses interviewed and summary of witness information provided: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 9. Further evidence of bullying (videos, photos, email, letters, etc.): __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 10. Is the alleged bullying substantiated, i.e., does the alleged conduct meet the definition of bullying as articulated in Board policy? Yes No 11. 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 ____Infringement of student’s rights at school 12. Conduct resulting in harm (in item 11 above) is on the basis of: ____National origin/ancestry/ethnicity ____Religion ____Physical, mental, emotional or learning disability ____Sexual orientation ____Gender/gender identity/expression ____Age ____Socioeconomic status ____Family status ____Physical appearance ____Weight ____Other distinguishing personal characteristics 12. Summary of investigation/Explanation of findings: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 13. Recommended disposition and/or recommended disciplinary action (including alternative discipline, support for targeted student, other intervention/referral) _______________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ 14. Recommendation of report to law enforcement? Yes No ____ Potential criminal violation ____ Potential civil rights violation Signature of investigator: _____________________________ If investigator is not building principal, copy to principal on ___________ Date Copy to Superintendent on _________ Date First Reading: 01/03/2013 Second Reading: 01/16/2013 |