JICK-E2 (FORM) Responding Form PDF Version of Form JICK-E2.pdf   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: ___________________________________________________________________