Discrimination, Harassment, or Bullying Incident

School Documentation Form: School Board Policy 1710/4021/7230

Name(s) of alleged offender(s) : / Age: / Grade:

INVESTIGATION:

1. Date of Incidents: ____/____/______/____/______/____/____

2. Where did incident occur (choose all that apply)

 On school property (location) ______

 On school bus (route number/Am or PM) ______

 At school sponsored activity or even off school property: ______

3. Place an “x” next to the statement that best describes what happened (choose all that apply):

 Hitting, kicking, shoving, spitting, hair pulling, or throwing something

 Getting another person to hit or harm student

 Teasing, name-calling, making critical remarks, or threatening, in person

 Teasing, name-calling, making critical remarks, or threatening, via a technological device

 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

 Sexual harassment using a cellular device or social networking site

 Other (specify) ______

4. What actions were taken to investigate this incident? (Choose all that apply)

 Interviewed student victim Date: _____/_____/_____

 Interviewed alleged offender(s) Date: _____/_____/_____

 Interviewed witnesses and/or bystanders: Date: _____/_____/_____

Names: ______

 Bystander statements collected in writing:

 Interviewed/communicated with teachers and/or school staff

 Communicated with victim’s parent/guardian Date: _____/_____/_____

 Communicated with alleged offenders parent/guardian date: _____/_____/_____

 Other (specify) ______

5. Why did the harassment or intimidation (bullying) occur (alleged motives)? Choose all that apply

 Because of race/national origin

 Because of gender or gender identity

 Because of socioeconomic status

 Because of academic status

 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)

 Because of race

 The reason is unknown

6. What corrective action were taken in this case: (choose all that apply)

 None were required, this was a false allegation

 None, the incident was not bullying and did not warrant any corrective action

 Student conference with offender Date: _____/_____/_____

 Student Warning

 Letter of apology

 Mediation and/or counseling

 Parent communication via conference, letter or phone call

 Disciplinary action:

 Detention

 In-school suspension

 Out -of-school suspension

 Other (specify)

7. Scheduled follow-up dates for victim and offender(s) if any:

8. Additional pertinent information gained during interview(s): ______

______

______