File: JICDE*-E-2 - Bullying Investigation Form

Instructions: Attach all reports, documents, evidence, and written accounts of the alleged bullying incident(s) to this investigation form.

Date of bullying report: ___________________

Date designated administrator received report: ______________________________

Date investigation started: ______________ Date investigation completed: __________

Investigator: _______________________________ Position/Title: _________________

I. Initial Review

Is alleged bullying incident(s) within the school district's authority to investigate?

[ ] Yes [ ] No If No, notify the Complainant. If Yes, move to next question.

Is alleged bullying incident(s) within the scope of this exhibit's accompanying policy?

[ ] Yes [ ] No

If No, the report should be promptly investigated pursuant to the applicable Board policy.

If Yes, promptly investigate the complaint pursuant to this exhibit's accompanying policy.

If possible criminal conduct is involved, was law enforcement notified?

[ ] Yes [ ] No

Date: ____________ Status, if known: ___________________________________

II. Bullying Report & Investigation Information

Name of Complainant: ___________________________________________________

Check one: [ ] Student [ ] Parent/Guardian [ ] Staff
[ ] Other (please specify):__________________________________

If a student, specify school and grade (optional): ____________________________

If a parent/guardian or other, provide contact information: _____________________

Is the Complainant the target of the alleged bullying being reported? [ ] Yes [ ] No

Does the Complainant wish to remain anonymous? [ ] Yes [ ] No

Student(s) reported as targets of alleged bullying (use reverse side if needed):

Name: ______________________________ School: ____________ Grade: _______
Name: ______________________________ School: ____________ Grade: _______
Name: ______________________________ School: ____________ Grade: _______

Person(s) reported as engaged in alleged bullying conduct (use reverse side if needed):

Person(s) reported as having witnessed or knowledge about the alleged bullying (use reverse side if needed)

Description of the alleged bullying incident(s), including date(s), time(s), and location(s), and the relationships of the involved individuals (use reverse side and/or additional pages if needed):_______________________________
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Did the Complainant allege that the student(s) were the targets of the alleged bullying in any of the following way(s)? (Check all that apply.)

[ ] Electronic devices (e.g., internet, Social medial platforms, text, email, cyber-bullying, etc.)

[ ] Written communication (e.g., email, handwritten notes, other written documents, etc.)

[ ] Physical act or conduct (e.g., pushing, hitting, destruction of property, stalking, etc.)

[ ] Verbal act or conduct (e.g., rumors, lies, name-calling, using derogatory slurs, etc.)

[ ] Social (e.g., purposeful exclusion, causing psychological harm, etc.)

[ ] Items depicting implied hatred or prejudice worn, possessed, or displayed

[ ] Other (please explain): _____________________________________________

Did the Complainant allege that the alleged bullying incident(s) was based on any of the following characteristics? (Check all that apply.)

            [   ] Race                                 [   ] Color                                [   ] National Origin
            [   ] Religion                            [   ] Sex                                   [   ] Ancestry
            [   ] Age                                   [   ] Marital Status                  [   ] Military Status
            [   ] Physical disability           [   ] Mental disability               [   ] Sexual orientation
            [   ] Gender identity                [   ] Gender-related identity   [   ] Gender-related expression
            [   ] Association with a person or group with one or more of the above actual or
            perceived characteristics
            [   ] Other (please specify): ___________________________________________

Evidence of alleged bullying provided to the school or in the school's possession

(e.g., school or bus surveillance video, cell phone video, photographs, digital images, emails, letters, written statement, notes, police reports, etc.)(attach all evidence): _________________________
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Have there been any prior incidents of bullying (alleged or substantiated) involving any or all of the involved individuals? ___________________________________________
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Additional school staff, if any, involved in investigation:

Name: ________________________________________ Position: ________________
Role in Investigation: ____________________________________________________

III. Special Education Review

Do any of the students involved in the alleged bullying incident(s) receive special education services under an IEP or a Section 504 Plan, or are any of the students in the process of being referred or evaluated for special education services? If Yes, refer to student's IEP or 504 Plan and contact special education director or Section 504 coordinator.

[ ] Yes [ ] No

Name: __________________________________ Date of contact: _______________
[ ] IEP [ ] 504 Plan [ ] Referral or Evaluation

IV. Interim Measures

Were any interim measures implemented for any of the involved students?

[ ] Yes [ ] No

Student Name: __________________________ School: ____________ Grade: _____

Description of interim measures (e.g., safety plan, duration, etc.) (attach documentation):

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Student Name: __________________________ School: ____________ Grade: _____
Description of interim measures (e.g., safety plan, duration, etc.) (attach documentation):
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Student Name: __________________________ School: ____________ Grade: _____

Description of interim measures (e.g., safety plan, duration, etc.) (attach documentation):

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V. Findings

Summary of findings of the investigation (i.e., determine whether the alleged conduct did or did not constitute bullying or other prohibited behavior under this exhibit's accompanying policy; determine whether the alleged conduct adversely affected any of the involved students' education or educational environment; and why) (attach additional pages if needed): _____

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IV. Parent/Guardian Notification

Document notification(s) to parents/guardians of students involved in the alleged incident(s) of bullying of the outcome of the investigation and any other information deemed appropriate by the investigator and designated administrator. The information may be provided, based on school district practice and taking into consideration the circumstances of the matter, in the form of a written report or meetings with each student's parents/guardians, and may include an overview of the investigation process, the findings of the investigation, and the actions taken to address the reported incident of bullying. Information shared with parents/guardians must be in accordance with applicable law and school Board policy.

Student Name: ____________________________ School: ___________ Grade:_____

Parent/Guardian Contacted: _______________________________________________

Staff Member (name and position/title): ______________________________________

Date(s) of Contact: ______________________________________________________

Type of Contact (phone, in person, email): ____________________________________

Summary of information provided, discussion, and next steps: ____________________

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