JICK-F

BULLYING INCIDENT REPORT FORM

SMITHFIELD PUBLIC SCHOOLS

(Investigation of allegations of Alleged Bullying and/or Cyber-bullying)

Name: ________________________________________ Student ID: ________________________________ Grade:_____________________

Date: _________________________ Time: ______________________ School: ____________________________________________________

Please answer the following questions about this reporting incident:

List the name of the alleged bully, and/or cyberbully. If name is not known, provide any other identifiable information: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Relationship between you and the alleged bully, and/or cyberbully: _________________________________________________________________________________________________________________________________________________________________

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

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) to bullying are adequate on (date) ________________________________________

Signature of School official designated to conduct investigation and determine Response

(if someone other than Principal): ____________________________________________________ Date: ________________________________

Signature of the Principal: ______________________________________________________________ Date: _______________________________

Submit to Superintendent or Designee

*Bullying, Cyberbullying and Retaliation are prohibited under the RI Safe Schools Act