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: _____________________________________________________________ _______________________________________________________________________
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