# JICK-E3 (FORM) REMEDIATION FORM
PDF version of [Form JICK-E3.pdf](https://documentation.cape.k12.me.us/attachments/3)
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### REMEDIATION FORM
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:\_\_\_\_\_\_\_\_\_\_\_\_
Date
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