Bullying Prevention And Intervention Incident Reporting Form Page 2
ADVERTISEMENT
1
2II. INVESTIGATION
1. Investigator(s):___________________________________________________
Position(s):________________________
2. Interviews:
□ Interviewed aggressor
Name: ___________________________________
Date: ___________________
□ Interviewed target
Name: ___________________________________
Date: ___________________
□ Interviewed witnesses
Name: ___________________________________
Date: ___________________
Name: ___________________________________
Date: ___________________
3. Any prior documented Incidents by the aggressor?
□ Yes □ No
If yes, have incidents involved target or target group previously?
□ Yes
□ No
Any previous incidents with findings of BULLYING, RETALIATION
□ Yes
□ No
Summary of Investigation:
(Please use additional paper and attach to this document as needed)
III. CONCLUSIONS FROM THE INVESTIGATION
1. Finding of bullying or retaliation:
□ YES
□ NO
□ Bullying
□ Incident documented as ___________________________
□ Retaliation
□ Discipline referral only_____________________________
2. Contacts:
□ Target’s parent/guardian
Date:______________
□ Aggressor’s parent/guardian
Date: _________________
□ District Equity Coordinator (DEC) Date: ______________ □ Law Enforcement
Date: ___________________
3. Action Taken:
□ Loss of Privileges
□ Detention
□ Suspension
□ Community Service
□ Education
□ Other ________________________________
4. Describe Safety Planning: _____________________________________________________________________________
Follow-up with Target: scheduled for __________________________ Initial and date when completed: _________
Follow-up with Aggressor: scheduled for _______________________ Initial and date when completed: _________
Report forwarded to Principal: Date__________________ Report forwarded to Superintendent: Date_________________
(If principal was not the investigator)
Signature and Title: ___________________________________________________________ Date: _________________
Appendix A/Page 2/2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Education