SMITHFIELD PUBLIC SCHOOLS
Name: ___________________________ Student ID: _____________________ Grade: ______
Date: ______________ Time: _________ School:____________________________________
Please answer the following questions about this reporting incident: List the name of the alleged harasser/perpetrator. If name is not known, provide any other identifiable information: ____________________________________________________________________________________________________________________________________________
Relationship between you and the perpetrator: ______________________________________________________________________
Describe the incident: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
When and where did it happen?___________________________________________________
Were there any witnesses? [ ] yes [ ] no
If yes, who? ______________________________
Other information, including previous incidents or threats: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I certify that all statements made in the complaint are true and complete. Any intentional false statement of fact will subject me to appropriate discipline. I authorize school officials to disclose the information I provide only as necessary in pursuing the investigation.
Signatures:
Complainant: ______________________________________________
Date: _____________
School official receiving complaint: ______________________________
Date: _____________
School official conducting follow‐up: ______________________________ Date: ____________
This document shall remain confidential
SMITHFIELD INVESTIGATION/RESPONSE FORM
Investigation start date: ___________________
Witness Interviews:
Name:
Brief Summary of Information Provided:
Date:
Documentation Reviewed:
Item:
Brief Summary of Information Provided:
Date:
Other Facts:
Finding: Incident ____ did ____ did not occur.
Date: ______________________
RESPONSE:
____ measures to provide the student with a safe educational environment;
describe in detail: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____ disciplinary action against the perpetrator(s) proposed to school authorities;
____ assessment by school psychologist and/or social worker (for both the victim and the perpetrator);
____ referral for appropriate counseling and/or social services;
____ notification to local law enforcement agency (when circumstances warrant criminal charges;
____ notification to student’s IEP team (when victim is a student with a disability);
____ notification to parents/guardians of the victim and the perpetrator of finding and response, if finding is that bullying occurred (specific information about discipline imposed on the perpetrator may not be disclosed to the parents of the victim)
Investigation/Response completion date ___________________
Follow up to ensure that response(s) are adequate on ________________ (date)
____________________________
Signature of School official designated to conduct investigation
____________________________
Date: ____________________________________________
Determine Response (if someone other than the Principal)
____________________________________________________
Signature of the Principal: ____________________________________________
Date: ______________________________________________
Submit to Superintendent or Designee
ADOPTED: December 4, 2017