NEPN/NSBA Code:  JICK-E3 

BULLYING: SUMMARY OF DISCIPLINARY AND REMEDIAL ACTIONS

This page is for use when a substantiated incident of bullying is entered into the Report of Substantiated Incident of Bullying in the Maine Department of Education’s NEO data reporting system. It is aligned with the NEO data categories.

This documentation is in reference to the alleged incident of bullying reported on:

[Date of incident]

Name of student who was found to have bullied (name is form tracking in school unit files only; do not report name of student or any personally identifying information to the Maine Department of Education)

Delineate the specific nature(s) of the incident:

 Cyberbullying

Electronic expression

Physical act or gesture

Retaliation

 Verbal/Oral

Written

Alternative discipline imposed for this student (actions taken):

Meeting with the student and the student's parent(s) or guardian(s)

Reflective activities, such as requiring the student to write an essay about the student's misbehavior

Mediation, but only when there is mutual conflict between peers, rather than one-way negative behavior, and    

          both parties voluntarily choose this option

Counseling

Anger management

Health counseling or intervention

Mental health counseling

Participation in skills building and resolution activities, such as social/emotional cognitive skills building, 

          resolution circles and restorative conferencing

Community service

The student received/will receive the following discipline actions (consequences):

Alternative Discipline

Detention

Weekend Detention

In-school suspension

Out-of-school suspension

Expulsion/Recommended for expulsion (middle or high school level only

The following serves as a record that a report of substantiated bullying has been submitted to the Maine Department of Education.    Date: 

Signature and position of person completing this form

Data reported to Maine DOE (NEO) on [Date] by

Signature, Position of Reporter

Copy to building principal on [Date]

Copy to Superintendent on [Date]

Approved: August 18, 2014

Revised: September 26, 2016

Revised: November 7, 2016

Revised: August 2, 2021