5131.911 Form 2 5131.911 Form 2Investigation Form
The purpose of this form is to provide a streamlined process to assess reported instances of challenging behavior.
This form is to be completed by the school climate specialist within a reasonable amount of time. Pursuant to the Federal Education Confidentiality Law (FERPA), students, parents or guardians, and school employees that completed the challenging behavior reporting form cannot receive a copy of this "Investigation Form" but will be provided with a copy of the "Response Process(es) Notification Form" after an assessment is completed.
Date "Challenging Behavior Reporting Form" received: _____________________________
Today's Date: _____________________________
Name of school climate specialist who received the report: ___________________________________
Were these events already reported to any school employee? If yes, please identify to whom, when, and what was reported
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Name of school community member who is reporting the incident: (student, parent or guardian, school or district employee, bystander, anonymous):
Name of student or students who were allegedly subjected to the challenging behavior: ____________________
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Name of person or persons who allegedly engaged in the challenging behavior: __________________________
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Where did the alleged incident occur? ___________________________________________________________
Date and time alleged incident occurred: (if known): _______________________________________________
Description of the alleged incident: _____________________________________________________________
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What investigative processes occurred? Answer all of the following questions below. A single incident may require an assessment into multiple areas. Please check all that apply.
Was this investigated as bullying? YES [ ] NO [ ]
Was this a verified act of bullying? YES [ ]NO [ ]
Was this investigated as cyberbullying? YES [ ] NO [ ]
Was this a verified act of cyberbullying? YES [ ]NO [ ]
Was this investigated as teen dating violence? YES [ ] NO [ ]
Was this verified teen dating violence? YES [ ] or NO [ ]
Was this investigated as an assault? YES [ ] NO [ ]
Was this a verified assault? YES [ ] or NO [ ]
Was this investigated as an act of physical violence? YES [ ] NO [ ]
Was this a verified act of physical violence? YES [ ] or NO [ ]
Was this investigated as a protected class violation/ harassment? YES [ ] NO [ ]
Was this a verified protected class violation/harassment? YES [ ] NO [ ]
Was this investigated as a Title IX violation? YES [ ] NO [ ]
Was this a verified Title IX violation? YES [ ] or NO [ ]
Was this a verified act of challenging behavior not listed above? YES [ ] NO [ ]
What was the response by the school climate specialist? (E.g., utilization of restorative practices, school-based threat assessment, safety plan, student support services) Additionally, provide the date of each response.
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If applicable, please provide any additional notes, observations, or actions taken as a result of this incident:
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Signature or E-signature of responding school climate specialist: _______________________________
Printed name: _______________________________________________________________________
Date of response: __________________________________