Policy Manual

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Policy JICK-E2

Date the alleged incident was reported: ____________  

Name of person investigating alleged incident(s): _________________________________  

Position/title of investigator: __________________________________________________  

Name of complainant/person reporting bullying incident(s): _________________________  

Complainant/reporter is (circle one): Student      Parent      School employee  

Coach/advisor      Volunteer      Other _____________  

Name(s) of alleged target(s): __________________________________________________  

Name(s) of alleged bully(ies): _________________________________________________    

Name(s) of potential witnesses: ________________________________________________  

Did the alleged incident(s) occur (check one or more):  

_____ on school property (including a school bus)  

_____ at a school sponsored activity  

_____ through use of technology  

_____ elsewhere  

Time and location(s) of incident(s): _____________________________________________  

Does the targeted student have an IEP? _____Yes ____No (If yes, refer to plan)  

Does the targeted student have a 504 plan? ___Yes ___No (If yes, refer to plan)  

Is the targeted student in the referral process for either? ___Yes ___No  

(If yes, specify)__________________________________  

If the targeted student receives special services, when were the Special Services Director and/or 504

Coordinator notified of the incident:  ____________________________________________

Person notified:_________________________________ Date:__________________  

Does the alleged bully have an IEP? ___Yes ___No (If yes, refer to plan)  

Does the alleged bully have a 504 plan? ___Yes ___No (If yes, refer to plan)  

Is the alleged bully in the referral process for either? ___Yes ___No  

(If yes, specify)______________________________________________________________  

If the alleged bully receives special services, when were the Special Services Director and/or 504 Coordinator  notified of the incident:  

Person notified:___________________________ Date:____________________  

*Please excuse any formatting errors.