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Documentation of Disciplinary and Remedial Actions Taken

Maine School Administrative District No. 31


This page is for use when a substantiated incident of bullying is entered into the Report of Substantiated Incident of Bullying in the Maine Department of Education’s NEO data reporting system. It is aligned with the NEO data categories.

This documentation is in reference to the alleged incident of bullying reported on:

[Date of incident]

Name of student who was found to have bullied _______________ (name is for tracking in school unit files only; do not report name of student or any personally identifying information to the Maine Department of Education)

Delineate the specific nature(s) of the incident:

_____ Cyberbullying

_____ Electronic expression

_____ Physical act or gesture

_____ Retaliation

_____ Verbal/Oral

_____ Written

Alternative discipline imposed for this student (actions taken):

_____ 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

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

The following serves as a record that a report of substantiated bullying has been submitted to the Maine Department of Education.

___________________________________________ Date: ______

Signature and position of person completing this form

Data reported to Maine DOE (NEO) on [Date] by ___________________________ Signature, Position of Reporter

Copy to building 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