# JICK-E2 (FORM) Responding Form PDF Version of [Form JICK-E2.pdf](https://documentation.cape.k12.me.us/attachments/2) --- ### Cape Elizabeth School Department RESPONDING FORM Date the alleged incident of bullying was reported: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Name of person investigating alleged incident(s): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Position/title of investigator: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Person reporting is (circle one) Student Parent/Guardian School Employee Coach/Advisor Volunteer Other\_\_\_\_\_\_\_\_\_\_\_\_\_ Name(s) of alleged target: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Name(s) of alleged bully(ies): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 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 the 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) If the alleged bully receives special services, when were Special Services Director and/or 504 Coordinator notified of the incident: Person notified: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Do the 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/they have been bullied, description of alleged incident(s) (dates and details): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Communications with parent/guardian(s) of student who believes he/she/they have been bullied (date(s) and details): Meeting/interview of alleged bully(ies) (dates and details): Communications with parent/guardian(s) of alleged bully(ies) (dates and details): Meeting/interview of persons identified as witnesses (dates and summary of information provided): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Further evidence of bullying examined (videos, photos, emails, letters, etc.): Measures taken pending conclusion of the investigation to ensure the safety of the student who believes he/she/they have been bullied: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Safety measures communicated to parent/guardian(s) of students who believes he/she/they have 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 \_\_\_\_ Sex \_\_\_\_ 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: Recommended 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 (date): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Copy to Superintendent (date): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Actions Taken by the 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/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 or cognitive skills building, resolution circles, and restorative conferencing \_\_\_\_\_\_ Community service Referral to law enforcement? \_\_\_\_ Yes \_\_\_\_ No Written notice has been provided to parent/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): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Actions Taken by the Superintendent** \_\_\_\_ Recommendation to Board for student expulsion \_\_\_\_ Action on student/parent/guardian 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: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_