Harassment/Bullying Investigation Form
Oklahoma School Security Act (70 O.S. § 24-100.3) requires each district to “Establish a
procedure for investigation of all incidents of harassment, intimidation, bullying, or threatening
behaviors reported to school officials for the purpose of determining the severity of the incidents
and their potential to result in future violence.” This form will assist districts in investigating
reported incidents of such behavior.
Person(s) Assigned to Investigation
Date Assigned: _________________________________________________________________
Name: ___________________________________________ Title: _______________________
Name: ___________________________________________ Title: _______________________
Incident Details
Student Affected:
____________________________________ Grade:_____ Class: ________________
Student(s) Initiating Bullying/Harassment:
____________________________________ Grade:_____ Class: ________________
____________________________________ Grade:_____ Class: ________________
Witness: ______________________________________________________________________
Witness: ______________________________________________________________________
Please list all witnesses including students and/or staff.
Documentation
Written statement of student victim Physical evidence (if applicable)
Written statement of witness/bystander Medical information (if applicable)
Written statement of alleged offender Copy of police report (if applicable)
Interview/notification of parents Copy of report form (if applicable)
Interview of staff witness Copy of incident notification (if applicable)
Action Taken
Interviewed alleged student victim Reviewed physical evidence
Interviewed alleged offender Reviewed medical information
Interviewed witnesses Reviewed bus incident information
Interviewed staff involved (list names) Reviewed student records
_______________________________ Reviewed social history between parties
_______________________________ Considered history of prior behavior
_______________________________ Other: ____________________________
Interviewed alleged student victim’s parents _________________________________
Interviewed alleged offender’s parents _________________________________
Investigation Findings of Harassment/Bullying Incident
_______ The Complaint is Sustained. Bullying or Harassment was verified.
_______The Complaint was Not Sustained. There was not enough verifiable proof that Bullying
or Harassment was taking place or the complaining party has refused to assist in the
investigation.
_______ Unfounded. The complaint was discovered to have no merit or the complaining party
has informed the investigator that the allegations were false and untrue.
Reported incident has been verified as bullying according to investigation procedure and state
law definitions.
Gesture, written, or verbal expression
Verbal fight
Written or verbal threat
Written note
Written or verbal rumors
Seclusion
Embarrassing the student
Other: ____________________________
Physical Act
Physical fight
Physical injuries
Other: ____________________________
Electronic communication
Identify the component used:
Cell phone
Audio or visual image
Instant message/email
Gaming
Social Networking
Blog
Other: ____________________________
Damage of student’s property
Property damage
Stolen or missing property
Other: ____________________________
Reasonable fear of harm to person or property
Fear of harm to person
Fear of harm to property
Other: ____________________________
Disrupt or interfere with school’s educational
mission or the education of student.
Changes in attendance: absences, tardies
Missing classes/parts of school day
Changes in grades
Changes in participation of school
activities
Avoidance of elements: lunch, bus, recess
Other: ____________________________
Follow Up/Disciplinary Action
Victim
Offender
Action Taken
Notes
None were warranted
Student contract
Review of bullying prevention policy
Conference with principal
Loss of privileges
Counseling interventions
School service work
Follow up/Monitoring
Loss of privileges on bus/loss of bus privileges
Detention
In-school assignments or intervention programs
Suspension
Assignment to alternative education facility
Student victim’s parent notification on completion of investigation:
Date of notification: ______________ Means of notification: Phone Letter Conference
Student offender’s parent notification on completion of investigation:
Date of notification: ______________ Means of notification: Phone Letter Conference
Reporting Purposes
This section is designed to collect bullying incident data consistent with the Oklahoma State
Department of Education’s reporting categories of the Annual Incident Report and the United
States Department of Education’s Office of Civil Rights. Please note, only check if your
investigation provides evidence upon which to base this conclusion. If the reporting categories
do not apply, please do not check.
USDE Office of Civil Rights
Bullying on the basis of gender
Bullying on the basis of sexual orientation
Bullying on the basis of race, color, or national origin
Bullying on the basis of disability
SDE Annual Incident Report
Bullying of students resulted in physical injury
Bullying of students without physical injury
Bullying of teachers/staff resulted in physical injury
Bullying of teachers/staff without physical injury
Bus incident
Gang related incident
Hate crime incident
Suicide attempted
Suicide completed
Completion of Investigation
Signature: _________________________________________________ Date:_______________
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