Caldwell County Schools

CALDWELL COUNTY SCHOOLS

BULLYING, HARASSMENT OR DISCRIMINATION

INVESTIGATION FORM

School Personnel Completing Form Position

Today’s Date School

Person Reporting Incident (From reporting form) Name:

Contact information:

Place an☒ in the appropriate box: ☐ Student☐ School Employee ☐ Parent/Guardian

☐ Person being bullied ☐ Community member ☐ Friend ☐ Other

Name of Student Victim

ID # Age Grade Daysabsent due to incident

Does student have an IEP or 504 plan (specify)

Name of alleged offender(s) (If known)
(Please Print) / Age / Grade / Is she/he a
student? Yes/No / School
(If known)

INVESTIGATION

Date of incident

Where did the incident occur? (choose all that apply)

☐ On school property- Location

☐ On school bus – Route Number

☐ At a school sponsored activity or event off school property – Name of event/activity

☐ On the way to/from school

☐ Other

Place an “X” next to the statement(s) that best describe what happened (choose all that apply):

☐ Any bullying, harassment, or discrimination that involves physical aggression

☐ Getting another person to hit or harm the student

☐ Teasing, name-calling, making critical remarks, or threatening, in person or by other means

☐ Demeaning and making the victim the object of jokes

☐ Making rude and/or threatening gestures

☐ Excluding or rejecting the student

☐ Intimidating, extorting, or exploiting

☐ Spreading harmful rumors or gossip

☐ Electronic communication (specify)

☐Other

What actions were taken to investigate this incident? (choose all that apply)

☐ Interviewed victim☐ Interviewed teacher and/or school staff

☐ Interviewed alleged offender(s)☐ Interviewed victim’s parent/guardian

☐ Interviewed witnesses – Names

☐ Witness statements collected in writing☐ Interviewed alleged offender’s parent/guardian

☐ Examined physical evidence☐ Reviewed any medical information available

☐ Conducted student record review☐ Obtained copy of police report

☐ Other (specify)

Why did the bullying, harassment, or discrimination occur (alleged motives)? (choose all that apply)

☐ Because of race☐ Because of national origin

☐ Because of gender☐ Because of socioeconomic status

☐ Because of academic status☐ Because of gender identity

☐ Because of physical appearance☐ Because of sexual orientation

☐ Because of mental, physical, development, or sensory disability

☐ Because of association with a person with one or more of the above characteristics

☐ To impress others☐ Just to be mean

☐ Because of another reason (specify)

☐ The reason is unknown

What corrective actions were taken in this case? (choose all that apply)

☐ None were required; this was a false allegation☐ Student conference

☐ Letter of apology☐ Student warning

☐ Parent letter☐ Parent conference

☐ Parent phone call☐ Referred to counseling

☐ Referred to ASAP☐ Transfer to another school

☐ Detention☐ In-school suspension

☐ Out-of-school suspension☐ Expulsion

☐ Other (specify)

Additional pertinent information gained during the interview: (Attach a separate sheet if necessary)

Investigator notes: (Attach a separate sheet if necessary)

Incident is determined to be:☐ Bullying

Date entered into PowerSchool as “Bullying”

☐ Not Bullying

Investigator’s Signature Date

Administrator’s Signature Date

Date faxed to Student Support Services, Attn: Jill Duffy, 828-726-0865

This form is to be confidentially maintained in accordance with the Family Educational Rights and Privacy Act, 20 U.S.C.§ 1232g.