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Signature: Date Received: <br /> Part II—Investigation <br /> 1. Investigator(s): Position(s): <br /> 2. Interviews: <br /> ❑ Interviewed aggressor Name: Date: <br /> ❑ Interviewed target Name: Date: <br /> ❑ Interviewed witnesses Name: Date: <br /> Name: Date: <br /> 3. Any prior documented incidents by the aggressor? Yes No <br /> 4. If yes, have incidents involved target or target group previously? Yes No <br /> 5. Any previous incidents with findings of BULLYING, RETALIATION Yes No <br /> Summary of Investigation: <br /> (Please use additional paper and attach to this document as needed) <br /> Part III—Conclusions from the Investigation <br /> 1. Finding of bullying or retaliation: <br /> Yes (please check one below) No (please check one below) <br /> Bullying Incident documented as <br /> Retaliation Discipline referral only <br /> 2. Contacts: <br /> Target's parent/guardian Date: Aggressor's parent/guardian Date: <br /> District Equity Coordinator (DEC) Date: Law Enforcement Date: <br /> 3. Action Taken: <br /> Loss of Privileges Detention (dates) Referral Suspension (dates) <br /> Community Service (dates) Other <br /> 4. Describe Safety Planning: <br /> Follow-up with Target: scheduled for Initial and date when completed: _ <br /> Follow-up with Aggressor: scheduled for Initial and date when completed: _ <br /> Report forwarded to Principal: Date <br /> Signature and Title: Date: <br /> 30 <br />