Harassment/bullying Investigation Form
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Oklahoma School Security Act (70 O.S. § 24-100.3) requires each district to “Establish a
procedure for investigation of all incidents of harassment, intimidation, bullying, or threatening
behaviors reported to school officials for the purpose of determining the severity of the incidents
and their potential to result in future violence.” This form will assist districts in investigating
reported incidents of such behavior.
Person(s) Assigned to Investigation
Date Assigned: _________________________________________________________________
Name: ___________________________________________ Title: _______________________
Name: ___________________________________________ Title: _______________________
Incident Details
Student Affected:
____________________________________
Grade:_____
Class: ________________
Student(s) Initiating Bullying/Harassment:
____________________________________
Grade:_____
Class: ________________
____________________________________
Grade:_____
Class: ________________
Witness: ______________________________________________________________________
Witness: ______________________________________________________________________
Please list all witnesses including students and/or staff.
Documentation
Written statement of student victim
Physical evidence (if applicable)
Written statement of witness/bystander
Medical information (if applicable)
Written statement of alleged offender
Copy of police report (if applicable)
Interview/notification of parents
Copy of report form (if applicable)
Interview of staff witness
Copy of incident notification (if applicable)
Action Taken
Interviewed alleged student victim
Reviewed physical evidence
Interviewed alleged offender
Reviewed medical information
Interviewed witnesses
Reviewed bus incident information
Interviewed staff involved (list names)
Reviewed student records
_______________________________
Reviewed social history between parties
_______________________________
Considered history of prior behavior
_______________________________
Other: ____________________________
Interviewed alleged student victim’s parents
_________________________________
Interviewed alleged offender’s parents
_________________________________
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