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Bullying Investigation Form

Maine School Administrative District No. 31

MSAD #31 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

____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: _____________________________________________________­­___________________

________________________________________________________________________


Recommendation 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]


First Reading: 01/03/2013

Second Reading/Adoption: 01/16/2013

Amendment First Reading: 03/29/2017

Second Reading/Adoption: 04/12/2017

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 10 school 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: _____________________________________________________________

_______________________________________________________________________