JICK-E2 MSAD #4 Bullying Investigation Form
NEPN/NSBA Code: JICK-E2 

M.S.A.D. #4 BULLYING INVESTIGATION FORM 

Date: ____________

1. Name of person investigating alleged incident(s): _______________________________

Position/title of investigator: __________________________________________________

Name of complainant/person reporting bullying: __________________________________

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

Complainant/reporter is (circle one): Student Parent School employee Coach/advisor Volunteer
Other ___________________________________________________________________

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

Name(s) of potential witnesses: ______________________________________________

2. Relationship between alleged target(s)/bully(ies): ______________________________

3. 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): _____________________________________________

_________________________________________________________________________

_________________________________________________________________________

4. Is this a first time occurrence or has the same or similar occurred previously? _________

5. Interview of complainant/reporter’s, description of alleged incident(s): _________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

6. Interview of alleged bully(ies): _______________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

7. Name(s) of potential witnesses, if any: ________________________________________

8. Witnesses interviewed and summary of witness information provided:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

9. Further evidence of bullying (videos, photos, email, letters, etc.):

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

10. Is the alleged bullying substantiated, i.e., does the alleged conduct meet the definition of bullying as articulated in Board policy?       Yes     No   (circle one)

11. Nature of harm incurred:

____Physical harm to student or damage to student’s property

____Student’s reasonable fear of physical harm or damage to property

____Infringement of student’s rights at school

12. Conduct resulting in harm (in item 11 above) is on the basis of:

____National origin/ancestry/ethnicity

____Religion

____Physical, mental, emotional or learning disability

____Sexual orientation

____Gender/gender identity/expression

____Age

____Socioeconomic status

____Family status

____Physical appearance

____Weight

____Other distinguishing personal characteristics

12. Summary of investigation/Explanation of findings: _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

13. Recommended disposition and/or recommended disciplinary action (including alternative discipline,
support for targeted student, other intervention/referral) ______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

14. Recommendation of report to law enforcement?    Yes    No     (circle one)

____ Potential criminal violation

____ Potential civil rights violation

Signature of investigator: ___________________________________________________

If investigator is not building principal, copy to principal on [________________________]

Date ________________________________

Copy to Superintendent on [____________________]
                                                            Date

Date _________________________________


M.S.A.D. #4