Bullying and Cyberbullying Responding Form

To be completed by the school principal or superintendent’s designee promptly [OR: within __ days] from the time that the Report Form is received.

Date the alleged incident of bullying was reported: ________________________

Name of school principal or superintendent’s designee investigating the report of alleged incident(s) of bullying:  _______________________________________
Position/title: ________________________________________

Details:

Person(s) reporting the alleged incident(s) of bullying (if indicated, but required if school staff, coaches or advisors): _____________________________________

Person who completed the Reporting Form (if indicated): ____________________

The person(s) reporting the alleged incident of bullying is:	student	parent	grandparent      guardian      school staff	   coach     advisor	other _________

Name of the student(s) or adult(s) who was believed to have been bullied: ______________________________________

Was the behavior related to the targeted student’s actual or perceived (as indicated in the description of the alleged incident on the Reporting Form):
	____Race/color
____Sex
____Sexual orientation (including gender identity and gender expression)
____Religion
____National origin/ancestry
	____Disability
If so; 
•	refer to Board policy ACAA: Harassment and Sexual Harassment of Students,
•	include the SAU’s Affirmative Action Officer in this investigation, and
•	if the behavior includes threats, violence, and/or property damage, it may be enforceable under the Maine Civil Rights Act and should be referred to local law enforcement.

Does the student have a 504 plan?     yes      no
Does the student have an IEP?   yes      no
If yes to either above questions, please refer to student’s 504 plan or IEP.
Is the student in the referral process for either?    yes      no
If the student receives Special Education services, when was the Director of Special Education or 504 Coordinator made aware of this situation?  date: ___________

Name of the student(s) or adult(s) who is alleged to have bullied: _______________

The reported alleged incident(s) occurred:
	 	_____ on school grounds 
		_____ on the school bus
	 	_____ at a school sponsored activity
	 	_____ through the use of technology – at home       at school 
		_____ elsewhere – (be specific) ____________________________

Date(s): _____________________________________________________
Time(s)/time(s) of day: ___________________________________________
Additional details known: __________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Have there been prior reports of alleged incidents of bullying or substantiated incident(s) of bullying involving the student(s) and/or adult(s)?    yes      no
If yes, please include details and outcomes: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Evidence of allegation(s) of bullying provided to the school or in the school’s possession used in this investigation:  

____school video cameras
____school bus camera
____cell phone video
____electronic photos
____printed photos
____email(s)	____letters
____phone conversation notes
____written statements
____hospital reports
____police reports
____other (specify)_______________ 	
		
Communication:

When did you contact the parent(s) or guardian(s) of the student(s) who was believed to have been bullied?
Date of communication(s):_________________________________________
Details of communication: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The school principal or superintendent’s designee met with the student(s) who was believed to have been bullied on: ___________
Details of communication:__________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

When did you contact the parent(s) or guardian(s) of the student(s) who was alleged to have bullied?
Date of communication(s):_________________________________________
Details of communication: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The school principal or superintendent’s designee met with the student(s) alleged to have bullied on: _________
Details of communication:__________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Did the person(s) reporting the alleged incident identify any witnesses?    yes      no
Name(s) of witness:______________________________________________

Did the school identify any witnesses?   yes      no
Name(s) of witness:______________________________________________

If yes, the school principal or superintendent’s designee met with the witness(es) on: ____________   Details of communication:_____________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Safety Measures:
	
Local or state law enforcement will be contacted for potential:   
	____ criminal charges 
	____ civil action under the Maine Civil Rights Act 
	____ N/A

What measures are being taken throughout the investigation to ensure the safety of the student who was believed to have been bullied?  ___________________________
____________________________________________________________
Attach safety measures (ie. Student Support & Safety Plan) to this Responding Form.

When was there communication with the parent(s) or guardian(s) of the student(s) who was believed to have been bullied about these safety measures?  
Date of communication(s):_________________________________________
Details of communication: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Determination of Bullying: 
Refer to the definition of bullying in policy JICK

Behavior(s) had the effect of: 
	____ Physically harming a student or damaging a student’s property; or
	____ Placing a student in reasonable fear of physical harm or damage to the
student’s property
OR 

Behavior(s) interfered with the rights of a student by:
	____ Creating an intimidating or hostile educational environment for the
student; or	
____ Interfering with the student’s academic performance or ability to
participate in or benefit from the services, activities or privileges provide
by a school

_____ None of the above

Summary of Investigation: (use additional sheet) 

Outcomes: (use additional sheet)

All findings and results shall be reported to the superintendent.

Is this a substantiated incident of bullying? 
 yes      no

If yes, refer to the Remediation Form (JICK-E3) to indicate specific nature(s) of the incident, the consequences, and actions taken for the student who has bullied.  This substantiated incident is to be reported to the superintendent, and to the Maine Department of Education.

If no, refer to the district-wide code of conduct and disciplinary policies for student behavior.

_____________________________________         	Date:  _____________ 
Signature and title of investigator	
			
If the investigator is not the school principal, copy to school principal on: __________	
											      Date

Copy received: ______________________________        Date: ____________
			Signature of school principal

Copy to Superintendent on: _______________
				        Date

Copy received: _______________________________        Date: ____________
			Signature of superintendent