Harassment/bullying Investigation Form Page 3
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3Follow Up/Disciplinary Action
Victim Offender
Action Taken
Notes
None were warranted
Student contract
Review of bullying prevention policy
Conference with principal
Loss of privileges
Counseling interventions
School service work
Follow up/Monitoring
Loss of privileges on bus/loss of bus privileges
Detention
In-school assignments or intervention programs
Suspension
Assignment to alternative education facility
Student victim’s parent notification on completion of investigation:
Date of notification: ______________ Means of notification: Phone Letter Conference
Student offender’s parent notification on completion of investigation:
Date of notification: ______________ Means of notification: Phone Letter Conference
Reporting Purposes
This section is designed to collect bullying incident data consistent with the Oklahoma State
Department of Education’s reporting categories of the Annual Incident Report and the United
States Department of Education’s Office of Civil Rights. Please note, only check if your
investigation provides evidence upon which to base this conclusion. If the reporting categories
do not apply, please do not check.
USDE Office of Civil Rights
Bullying on the basis of gender
Bullying on the basis of sexual orientation
Bullying on the basis of race, color, or national origin
Bullying on the basis of disability
SDE Annual Incident Report
Bullying of students resulted in physical injury
Bullying of students without physical injury
Bullying of teachers/staff resulted in physical injury
Bullying of teachers/staff without physical injury
Bus incident
Gang related incident
Hate crime incident
Suicide attempted
Suicide completed
Completion of Investigation
Signature: _________________________________________________ Date:_______________
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