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Bullying Investigation Form

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