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Form JICK-E2 Responding Form

PDF Version of Form JICK-E2.pdf

 

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:




 

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: ___________________________________________________________________

 

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