Bullying and Cyberbullying Remediation Form

The intent of remediating a substantiated incident of bullying is to counter the negative impact of bullying and to reduce the risk of future bullying incidents.

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

Name of student who was found to have bullied (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

Was the student referred to law enforcement?  yes      no
Outcome(s):____________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Additional details of disciplinary actions taken:____________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

[DOCUMENTATION OF ALL REMEDIATION ACTIONS MUST RESPECT CONFIDENTIALITY OF STUDENT INFORMATION AS PROVIDED BY FEDERAL AND MAINE LAW AND REGULATIONS] 

_____________________________________         	Date:  _____________ 
Signature of principal or superintendent’s designee completing this form	

_____________________________________
Title of superintendent’s designee		

If this person is not the school principal, copy to school principal on: __________	
											Date

Copy received: _______________________________        Date: ____________
			Signature of school principal

Copy to Superintendent on: _______________
				        Date
Copy received: _______________________________        Date: ____________
			Signature of Superintendent

This substantiated incident of bullying was reported to the Maine Department of Education without personally identifying information 
on: _____________________    initialed by: _________