Bullying Incident/Investigation Form 21/22

Investigative Report of Alleged Bullying

Incident Reported To*

Incident Reported By*

Complainant's Name*

Complainant - Person making the complaint

Complainant's Designation*

Select

If Student, state age

If Other, please state.

School of the Complainant*

Select

Respondent's Name*

Respondent - Person responsible for the harassment

Respondent's Designation*

Select

If the respondent is a student, please state age*

If the respondent's designation is "other", please explain*

School of Respondent*

Select

Name of any witnesses to the complaint*

Where did the alleged incident occcur?*

When did the alleged incident occur?*

Date Respondent was notified*

File Attachments - nature of the complaint*

Attach the nature of the COMPLAINT, and the nature of the RESPONSE including a detailed account of the activity in question. Include, as much detail as possible, an exact recitation of words used, and/or nature of alleged bullying.

Drag and drop files here or

Respondent’s answer to the complaint*

Respondent agrees with the complaint as stated by Complainant

Respondent disagrees with the complaint as stated by Complainant

An investigation of the complaint

Found grounds to substantiate the report as a bullying incident

Did not find grounds to substantiate the report as a bullying incident

Did not find enough information to make a judgment on the allegations

Incident was:*

Verbal

Physical

Social/Relational

Written or Electric

Was there physical injury as a result of the incident?*

Yes

Was Complainant seen by a nurse?*

Yes

If yes, date seen by nurse:

Corrective Action/Consequence/Resolution

(Provide attachment, if necessary)

Remedial Support Offered to Complainant*

(ie. Student Support Plan)

Remedial Support*

Parent/Guardian accepted remedial support

Parent/Guardian denied remedial support

Check here if complaint was moved to the formal process

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