JICK-E2 - Portland Public Schools Bullying Investigation Form
Book: J
Section: Students
Title: Portland Public Schools Bullying Investigation Form
Code: JICK-E2
Status: Active
Adopted: June 21, 2016
PORTLAND PUBLIC SCHOOLS 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
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
____ 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
JICK-E2 - Portland Public Schools Bullying Investigation Form.pdf (25 KB)