Policy Manual

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Policy JICK-E3

This page is for use when a substantiated incident of bullying is entered into the Report of  Substantiated Incident of Bullying in the Maine Department of Education’s NEO data reporting  system. It is aligned with the NEO data categories. 

This documentation is in reference to the alleged incident of bullying reported on:  [Date of incident]

Name of student who was found to have bullied _______________ (name is for tracking in  school unit files only; do not report name of student or any personally identifying  information to the Maine Department of Education) 

1. Delineate the specific nature(s) of the incident:  

_____ Cyberbullying  

_____ Electronic expression  

_____ Physical act or gesture  

_____ Retaliation  

_____ Verbal/Oral  

_____ Written

2. The student received/will receive the following disciplinary actions (consequences): 

 _____ Alternative Discipline  

_____ Detention  

_____ Weekend Detention  

_____ In-school suspension  

_____ Out-of-school suspension  

_____ Expulsion/Recommended for expulsion  

3. Alternative discipline imposed for this student (actions taken):  

_____ Meeting with the student and the student's parent(s) or guardian(s)  

_____ Reflective activities, such as requiring the student to write an essay about the  student's misbehavior  

_____ Mediation, but only when there is mutual conflict between peers, rather than  one-way negative behavior,

and both parties voluntarily choose this option  

_____ Counseling  

_____ Anger management  

_____ Health counseling or intervention  

_____ Mental health counseling  

_____ Participation in skills building and resolution activities, such as social/   emotional/ cognitive skills

building, resolution circles and restorative  conferencing  

_____ Community service  

The following serves as a record that a report of substantiated bullying has been submitted to the  Maine Department of Education.

___________________________________________ Date: ______  

Signature and position of person completing this form  

Data reported to Maine DOE (NEO) on [Date] by ___________________________   

Signature, Position of Reporter  

Copy to building principal on [Date]  

Copy to Superintendent on [Date]  

Approved: 2/27/17

*Please excuse any formatting errors.