PDF version of Form JICK-E3.pdf


This page is for use when a substantiated incident of bullying is entered into the Report of Substantiated Incident of Bullying in the Maine Department of Education’s NEO data reporting system.  It is aligned with the NEO data categories.


This documentation is in reference to the alleged incident of bullying reported on:____________



Name of student who was found to have bullied _______________________________________ 

(Name is for tracking in school unit files only; do not report name of student or any personally identifying information to the Maine Department of Education)


Delineate the specific nature(s) of the incident:

_____ Cyberbullying

_____ Electronic expression

_____ Physical act or gesture

_____ Retaliation

_____ Verbal/oral

_____ Written


Alternative discipline imposed for this student (actions taken):

_____ Meeting with the student and the student’s parent(s) or 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

_____ Participation in skills building and resolution activities, such as social-emotional or cognitive skills building, resolution circles, and restorative conferencing

_____ Community service


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


The following serves as a record that a report of substantiated bullying has been submitted to the Maine Department of Education.


__________________________________________ _____________________________

Printed Name (person completing this form) Position


__________________________________________ _____________________________

Signature Date


__________________________________________ _____________________________

Printed Name (person reporting to ME DOE) Position


__________________________________________ _____________________________

Signature Date 



Copy to building principal - Date



Copy to Superintendent - Date

Revision #3
Created 31 March 2022 13:23:35 by Troy Patterson
Updated 14 February 2023 21:21:36 by Troy Patterson