JICK-E3 Documentation of Disciplinary and Remedial Actions Taken
NEPN/NSBA Code: JICK-E3 

DOCUMENTATION OF DISCIPLINARY AND REMEDIAL ACTIONS TAKEN 

____ Notification of law enforcement authorities, if warranted (if any question, principal should consult with Superintendent first)

Date: ____________ Reported to: ________________________________________________________

____ In school suspension 

____ Out of school suspension 

____ Recommendation for expulsion

____ Alternative discipline/restorative justice (describe): _______________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____ Other intervention: ________________________________________________________

____ Support for targeted student: ________________________________________________

____ Counseling/referral to services (targeted student), if suitable

____ Counseling/referral to services (bully), if suitable

____ If bully is school employee or administrator, recommendation for action to be taken by Superintendent (any action must be consistent with collective bargaining agreement or individual contract).

____ If bullying by other person (e.g., volunteer, visitor, contractor), action taken:___________

        ___________________________________________________________________________

        ____ If bullying by school-affiliated organization, action taken: _________________________

        __________________________________________________________________________

Written Notification to Parents/Guardians of Targeted Student, Including Measures Being Taken to Ensure Student’s Safety:

Date: ___________ By: ____________________________ (Attach copy of notification here)

Written Notification to Parents/Guardians of Student Found to Have Engaged in Bullying Behavior, Including Process for Appeal:

Date: ___________ By: ____________________________ (Attach copy of notification here)

Signature of building principal:_____________________________________ Date: __________

Copy sent to Superintendent on [_____________]
                                                             Date

DOCUMENTATION OF APPEALS OF PRINCIPAL’S DECISION

Date appeal submitted: ________

All appeals to the Superintendent must be submitted, in writing, within 14 calendar days of the building principal’s decision, to the Central Office.

ACTIONS TAKEN BY SUPERINTENDENT 

________ Recommendation to Board for student expulsion

________ Action taken against employee: (If confidential employment action, in personnel file)

________ Recommendation to Board for suspension/revocation of sanctioning/approval of school- affiliated organization

________ Action on appeal of principal’s decision: __________________________________________

___________________________________________________________________________________

_______ Other:______________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________


M.S.A.D. #4