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: __________________________

Designated administrator: __________________________

Date designated administrator received report: __________________________

Date investigation started: __________________________

Date investigation completed: __________________________

Investigator: ______________________________________

Position/Title: ______________________________________

I. Initial Review

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

[ ] Yes [ ] No If No, notify the Complainant and provide resources for support. If Yes, move to next question.

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

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 [ ] N/A

Date: ___________________ Contact person: _____________________________

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: __________

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

Name: _________________________________ [ ] Student [ ] Staff [ ] Other

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

Name: _________________________________ [ ] Student [ ] Staff [ ] Other

Description of the alleged bullying incident(s), including date(s), times(s), and locations(s), methods, (e.g., physical, verbal, written, electronic/social media, psychological, social, images or items displayed or worn, etc.), how often the incident(s) occurred, whether an imbalance of power exists between the target and the perpetrator/the relationships of the involved individuals, and whether the alleged bullying was based on any protected category under federal or state law or school board policy. (use reverse side and/or additional pages if needed):

____________________________________________________________________________

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 media 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, if yes, refer to the appropriate policy and procedure addressing nondiscrimination/equal opportunity or sexual harassment under Title IX.)

[ ] Race [ ] Color [ ] National Origin

[ ] Religion [ ] Sex [ ] Ancestry

[ ] Age [ ] Marital status [ ] Military Status

[ ] Physical disability [ ] Mental disability [ ] Sexual orientation

[ ] Gender identity [ ] Creed [ ] Gender Expression

[ ] Family Status

[ ] 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 statements, notes, police reports, etc.) (attach all evidence):

____________________________________________________________________________

Have there been any prior incidents of bullying (alleged or substantiated) involving any or all of the involved individuals?

____________________________________________________________________________

Additional school staff, if any, involved in investigation:

Name: __________________________________________ Position: _____________________

Role in Investigation: ____________________________________________________________

Name: __________________________________________ Position: _____________________

Role 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

Name: __________________________________ Date of contact: _____________

[ ] IEP [ ] 504 Plan [ ] Referral or Evaluation

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 measure (e.g., safety plan, duration, etc.) (attach documentation):

____________________________________________________________________________

Student Name: ____________________________ School: _____________ Grade: ___________

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

____________________________________________________________________________

Student Name: ____________________________ School: _____________ Grade: ___________

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

____________________________________________________________________________

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):

____________________________________________________________________________

VI. Parent/Guardian Notification

Document notification(s) to the students involved in the alleged incident(s) of bullying and their parents/guardians 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 policy, procedures, and practice, as well as taking into consideration the circumstances of the matter, in the form of a written report or meetings with each student and the 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 students and 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: