Fillable Bullying, Harassment, or Intimidation Investigation Form (Montgomery Schools)

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Bullying, Harassment, or Intimidation Investigation Form (Montgomery Schools)

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DISTRIBUTION:
1) School inputs information from this form to the incident reporting system in Synergy, 2) Paper copies of this form kept in School
Confidential File, 3) Serious Incident reporting may be required and Student Welfare and Compliance contacted.
Bullying, Harassment, or Intimidation Investigation Form
Office of District Operations—Student Welfare and Compliance
MONTGOMERY COUNTY PUBLIC SCHOOLS • Rockville, Maryland 20850
This form is to be maintained confidentially in accordance with the Safe Schools Reporting Act of 2005, Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g.
MCPS Form 230-36
June 2022
Page 1 of 3
INSTRUCTIONS
Upon receipt of MCPS Form 230-35, Bullying, Harassment, or Intimidation Reporting Form, the school principal/designee must promptly
conduct an adequate, reliable, and impartial investigation. The investigation must be documented by completing this form. Principal/
Designee must use this form, MCPS Form 230-36, Bullying, Harassment, or Intimidation Investigation Form, to promptly and appropriately
investigate reports of bullying, harassment, or intimidation consistent with due process rights, within two school days after receipt of a
reporting form or as timely as possible for school administration or administrative designee.
School Administrator/Designee Completing Form ______________________________________ Position______________________________
Today’s date _____/_____/______ School ___________________________________ School System
MONTGOMERY COUNTY PUBLIC SCHOOLS
PERSON REPORTING INCIDENT (Please print all information)
Name _______________________________________________________________________________________________________________
Telephone_____-_____-______ Email ___________________________________________________________________________________
Check the appropriate box:
o Student o Parent/guardian/caregiver of a student o Close adult relative of a student o School staff o Bystander
1. COMPLAINANT(S): PERSON(S) ALLEGED TO BE THE VICTIM
Name Age School (if known)
IEP
(Y/N)
Days absent as a result of
the incident (if known)
2. ALLEGED WITNESS(ES) (if known)
Name Age (if known)
3. RESPONDENT(S): PERSON(S) ALLEGED TO BE THE OFFENDER (if known)
Name School (if known)
Age
(if known)
Student:
(Y/N)
IEP
(Y/N)
Days absent as a
result of the incident
(if known)
4. INVESTIGATIVE ACTIONS
a. Interviews Conducted (check all that apply):
o Person Reporting Alleged Incident o Complainant o Respondent o Alleged Witnesses
o School Nurse o Law Enforcement o Alleged Targeted Student’s Parent/Caregiver o Alleged Offender’s Parent/Caregiver
o School Staff o Previously Investigated and Documented Date_____/_____/______
o Other (specify) ___________________________________________________________________________________________________
b. Relevant Documentation/Evidence Collected/Reviewed (check all that apply):
o Witness Statements o Law Enforcement Documentation o Medical Records o Social Media Sites
o Video Evidence o Conducted Student Record Review o Other (specify) _______________________________________________
CLEAR FORM
MCPS Form 230-36
Page 2 of 3
5. WHERE WAS THE INCIDENT REPORTED TO HAVE HAPPENED? (check all that apply)
o On school property
o School Cafeteria
o Classroom
o Media Center
o Office Area
o Hallway/Stairs/Transitions
o Playground Campus
o School-sponsored after-school program
o Restroom
o Locker room/Gym
o On the way to/from school
o On a school bus
o Off school property or at a school-sponsored activity or event
o Personal mobile device on school property
o Personal mobile device off school property
o Personal mobile device during virtual learning
o Other (please specify) __________________________________
6. ALLEGED MOTIVE AS TO WHY THE HARASSMENT, INTIMIDATION, OR BULLYING OCCURRED (check all that apply)
o Because of race/ethnicity
o Because of national origin
o Because of religion
o Because of sex
o Because of immigration status
o Because of family/parental or marital status
o Because of socioeconomic status
o Because of academic performance
o Because of sexual orientation
o Because of gender expression
o Because of gender identity
o Because of disability
o Because of physical appearance
o To impress others
o Just to be mean
o Retaliation
o Gang-related/Gang recruitment
o Human trafficking/Prostitution recruitment
o Because of another reason (specify)
o The reason is unknown
o Determined not to be Bullying
o Determined not to be Harassment
o Determined not to be Intimidation
7. OUTCOME OF THE INVESTIGATION
o It was determined that an incident(s) of bullying, harassment, or intimidation has occurred and the appropriate consequences,
interventions, and supports have been applied based on local school-system policies and procedures.
o It was determined not to be bullying, harassment, or intimidation due to a lack of a preponderance of evidence.
o This has been identified as a false allegation.
o The alleged incident could not be verified as bullying, harassment, or intimidation.
o Determined as a conflict or other inappropriate behavior, and did not rise to the level of bullying, harassment, or intimidation.
8. INTERVENTIONS/SUPPORTS FOR RESPONDENT(S) (check all that apply)
o Administrative conference with student
o Restorative approach
o Referral to school counselor or student support team
o Parent outreach (phone call, email, text message)
o Student/Parent conference
o Detention
o In-school suspension
o Out-of-school suspension
o Behavior contract
o Alternative placement/setting
o Community service
o Separation from other student to include transfer or change
in schedule
o Referral to law enforcement
o Consult with IEP chair
o Other (please specify) __________________________________
9. INTERVENTIONS/SUPPORTS FOR COMPLAINANT(S) (check all that apply)
o Plan of Support to include a “go to” adult in the school
o Student/Parent conference
o Referral to counselor or therapist
o Parent outreach (phone call, email, text message)
o School counseling supports
o Developed template for safety plan
o Consult with IEP chair
o Other (please specify) __________________________________
10. DID A PHYSICAL INJURY RESULT FROM THE INCIDENT?
o Non observed o  Injury observed o  Medical documentation provided
11. WAS THE COMPLAINANT ABSENT FROM SCHOOL AS A RESULT OF THE INCIDENT?
o  Yes o  No If yes, how many days was the complainant absent from school as a result of the incident? _________
SIGNATURE
I understand that my electronic submission of this form and my electronic signature are intended to be, constitute, and are equivalent to my personal signature.
School Administrator or Designee Signature _______________________________________________________________ Date
_____/_____/______
click to sign
signature
click to edit
MCPS Form 230-36
Page 3 of 3
The Safe Schools Reporting Act of 2005 requires all Maryland school systems to report incidents of bullying,
harassment, or intimidation against students attending public schools. The law provides for any student,
parent/guardian, close adult relative of the student, school staff member, or bystander to report an
incident of bullying, harassment, or intimidation.
In accordance with Maryland law, bullying, harassment, or intimidation means intentional conduct,
including verbal, physical, or written conduct or an intentional electronic communication that creates
a hostile educational environment by substantially interfering with a student’s educational benefits,
opportunities, or performance, or with a student’s physical or psychological well-being, and is: (1)Either
(a) motivated by an actual or perceived personal characteristic, including race, ethnicity, color, ancestry,
national origin, religion, immigration status, sex, gender, gender identity, gender expression, sexual
orientation, family/parental status, marital status, age, physical or mental disability, poverty and
socioeconomic status, language, or other legally or constitutionally protected attributes or affiliations; (b)
sexual in nature; or (c) threatening or seriously intimidating; and (2) Either (a) occurs on school property,
at a school-sponsored activity or event, or on a school bus; or (b)substantially disrupts the orderly
operation of a school.
Cyberbullying is a form of bullying that takes place over digital devices like cell phones, computers, and
tablets. Cyberbullying can occur through texting, apps, or online via social media, forums, or gaming
where people can view, participate in, or share content. Cyberbullying includes sending, posting, or
sharing negative, harmful, false, or hurtful content about another student. It can include sharing personal
or private information about someone else, causing embarrassment or humiliation.
Montgomery County Public Schools created MCPS Form 230-35, Bullying, Harassment, or Intimidation
Reporting Form, which can be downloaded from the MCPS website, www.montgomeryschoolsmd.org.
Once a school receives a report, an investigation must be completed and documented on MCPS Form
230-36, Bullying, Harassment, or Intimidation Incident School Investigation Form, which is also available
from the MCPS website.
Procedure for implementing the Safe Schools Reporting Act of 2005 are as follows:
• Once MCPS Form 230-35, Bullying, Harassment, or Intimidation Reporting Form, has been submitted to
the school, the principal/designee is required to conduct an investigation.
• MCPS Form 230-36, Bullying, Harassment, or Intimidation Incident School Investigation Form, is
completed by the principal/designee.
• Information from MCPS Form 230-36, Bullying, Harassment, or Intimidation Incident School
Investigation Form is entered into the incident reporting system in Synergy. To enter the incident
reporting system in Synergy, open through the name of the student who was bullied.
• Each school will maintain a confidential file of completed MCPS Forms 230-35, Bullying, Harassment,
or Intimidation Reporting Form, and MCPS Form 230-36, Bullying, Harassment, or Intimidation Incident
School Investigation Form.
• Should the act of bullying, harassment, or intimidation necessitate a request for police assistance,
timelines and community notification procedures may need to be adjusted to accommodate police
investigation.
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Completed 8 July 2022

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