JICK-E3 (FORM) REMEDIATION FORM

PDF version of Form JICK-E3.pdf 

 

 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