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JICK-E1- RSU 1 Bullying Report Form, Draft

***Bullying or suspected bullying is reportable in person or in writing (including anonymously) to school personnel. ***

Date the alleged incident of bullying is being reported: _____________________________

Person(s) reporting the alleged incident(s) of bullying (this is optional as reports can be made anonymously, except when reported by staff, coaches and advisors): ____________________

Person(s) completing this form (if different than person listed above and not anonymously reporting): ___________________

Person reporting is: student parent grandparent guardian

school staff coach advisor other _____________________________

Contact information of person reporting (optional):

home or work phone: [( )] Cell phone: [( )_______________________ ]

email:_______________________________________ [ ]

home address: ________________________________________________________

Details

Name of student(s) who is believed to have been bullied: _________________________________

Name of the student(s) or adult(s) who is alleged to have bullied: ______________________

Date(s): _____________________________________________________________

Time(s)/time(s) of day: __________________________________________________

Location(s) of incident(s): ________________________________________________

Were there any witnesses? ◻ yes ◻ no

May the school personnel conducting an investigation contact these witnesses? ◻ yes ◻ no

If so, please provide names of witnesses to be contacted during the investigation: ___________________________________________________________________

___________________________________________________________________

Please provide a description of incident(s) and the outcome. Please include any supporting documentation.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(use additional pages, if needed)

  • When did you contact the parent/guardian of the student who was believed to have been bullied? __________________________________________

  • Date of when the principal met with the student who was believed to have been bullied: __________________________________________________

  • Date of when the principal contacted the parent/guardian of the student who was alleged to have bullied: _______________________________________

Determination of Bullying:

Refer to the definition of bullying in policy JICK

Behavior(s) had the effect of:

____ Physically harming a student or damaging a student's property; or

____ Placing a student in reasonable fear of physical harm or damage to the student's

property

**OR **

Behavior(s) interfered with the rights of a student by:

____ Creating an intimidating or hostile educational environment for the student; or

____ Interfering with the student's academic performance or ability to participate in or

benefit from the services, activities or privileges provide by a school

_____ None of the above

Was the behavior related to the targeted student's actual or perceived (as indicated in the description of the alleged incident on the Reporting Form):

____Race/color

____Sex

____Sexual orientation (including gender identity and gender expression)

____Religion

____National origin/ancestry

____Disability

If so;

  • refer to Board policy ACAA: Harassment and Sexual Harassment of Students,

  • include the SAU's Affirmative Action Officer in this investigation, and

  • if the behavior includes threats, violence, and/or property damage, it may be enforceable under the Maine Civil Rights Act and should be referred to local law enforcement.

_____________________________________ Date: _____________

Signature and title of investigator

If the investigator is not the school principal, copy to school principal on: __________

Date

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