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Form JICK-E2 Responding Form

PDF Version of Form JICK-E2.pdf




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: ___________________________________________________________________