Policy Details

4118.112 and 4218.112 FORM 1 Sexual Harassment

4118.112/4218.112
Form 1

Litchfield Public Schools

BULLYING, CYBERBULLYING, HARASSMENT, SEXUAL HARASSMENT,
DISCRIMINATION AND RETALIATION INCIDENT
INVESTIGATION FORM

This form is to be used by a principal, safe school climate specialist or coordinator, civil rights coordinator or their designee(s) to document an investigation of conduct reported as or suspected to be cyberbullying, sexual harassment, discriminatory harassment based upon membership in a protected class or retaliation against a student or students. Investigations shall be thorough, impartial and prompt (under the circumstances) and follow timelines for responsiveness as set forth in the law, board policy and applicable grievance procedures. ________________________________________________________________________________________________

COMPLETE ALL APPLICABLE SECTIONS AND ATTACH ADDITIONAL SHEETS IF NECESSARY

1. Investigator(s):

Name: ________________________________________________________________________________________

Position(s): ____________________________________________________________________________________

2. Name of complainant/title/position: _____________________________________________________________

3. Information about the incident:

Name of Target(s): ______________________________________________________________________________

Name of Aggressor(s): ___________________________________________________________________________

Date(s) of Incident(s): ___________________________________________________________________________

Time When Incident(s) Occurred: _________________________________________________________________

Location of Incident(s) (Be as specific as possible): ___________________________________________________

If Cyberbullying, what is the point of origin: ________________________________________________________

4. Witnesses (List people who saw the incident or have information about it.):

Name: _________________________________________ Student Staff Other ________________________

Name: _________________________________________ Student Staff Other ________________________

Name: _________________________________________ Student Staff Other ________________________

Name: _________________________________________ Student Staff Other ________________________

(Be sure to ask both the target and aggressor for suggested names of any witnesses)

5. Date of Formal Written Complaint/Report: __________________________________________________

AND/OR

Date of Oral Complaint: __________________________________________________________________

AND/OR

Date conduct was witnessed by employee: ___________________________________________________

(School employees who witness acts of bullying or receive reports of bullying must orally notify the safe school climate specialist, or another school administrator if the safe school climate specialist is unavailable, not later than one school day after such school employee witnesses or receives a report of bullying, and must file a written report not later than two school days after making such oral report)

Summarize incident (attach complaint/written report): _________________________________________________

__________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6.Date of Commencement of Investigation: ____________________________________________________

7. Notification of Commencement of Investigation:

To Parent/Guardian of Aggressor: _________________________________________________________

Date /Manner of Notification: _____________________________________________________________

To Parent/Guardian of Target: ____________________________________________________________

Date /Manner of Notification: _____________________________________________________________

(The parents or guardians of the student alleged to have committed an act(s) of bullying and those of the student against whom such alleged act(s) were directed are required by law to receive prompt notice that such investigation has commenced.)

8. Date of Completion of Investigation: _____________________________________________________

9. Date of Formal Written Summary Report or Findings: _____________________________________

10. Date of Written Notification of Findings: *

To Parent/Guardian of Aggressor: ________________________________________________________

To Parent/Guardian of Target: ___________________________________________________________

To others (specify): ____________________________________________________________________

11. Date of Invitation to Parent Meeting: *

To Parents/Guardians of Target __________________________________________________________

To Parents/Guardians of Offender(s)

(*Notification of verified bullying is required to be provide to parent/guardian of both the target and aggressor not later than 48 hrs. after completion of the investigation; such notification may include required invitation to a parent meeting)

12. Interviews:

Interviewed aggressor(s)

Name: ______________________________________________________________________________

Date (s): _____________________________________________________________________________

Written Statement Yes No If yes, attach written statement(s)

Oral Statement Yes No

Summarize oral statement: (including date/place it was given and name(s) of any other individuals

present) ____________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Interviewed target(s)

Name: ________________________________________ Date (s): ______________________________

Written Statement Yes No If yes, attach written statement(s)

Oral Statement Yes No

Summarize oral statement (including date/place it was given and name(s) of any other individuals

present)

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Interviewed witnesses

Name: _________________________________________ Date: ________________________________

Written Statement Yes No If yes, attach written statement(s)

Oral Statement Yes No

Summarize oral statement (including date/place it was given and name(s) of any other individuals

present)

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

(Attach any written statements and/or additional sheets if needed for summary of oral statements)

13. Any prior documented incidents by the aggressor(s)? Yes No

If yes, have incidents involved target or target group previously? Yes No

Any previous incidents with findings of BULLYING, CYBERBULLYING, HARASSMENT,

SEXUAL HARASSMENT, DISCRIMINATION AND/OR RETALIATION?

 Yes  No

If yes, specify: _________________________________________________________________________

14. List and describe all documentation considered as part of the investigation (i.e. bus referral/report, student records, student attendance records, medical records, nurse referral, disciplinary referral, police report, photographs, surveillance tapes, emails, text messages, postings, other physical evidence(attach copies whenever possible): ________________________________________________________________________ _________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

(Care is required when dealing with evidence consisting of pictures or images which may constitute child pornography. Do not copy or further disseminate images. Consider contacting the local police when in doubt).

15. Summarize your investigation (include who was spoken to, where and when/dates as well as who conducted or witnessed such interviews, include the substance of any oral/written statements given, indicate credibility as appropriate, specify what documentation or other information was considered and the weight given to it and why, state any conclusions reached regarding the incident, individuals, or the veracity or reliability of individuals/ information and note where information was or failed to be corroborated). __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

16. Check all of the following that apply with respect to this investigation:

□ Target and offender(s) are students in the same school or school district

□ Target and offender(s) are not students in the same school district

□ Target and offender(s) are currently in or have recently been in a dating relationship

□ Offender is a school employee

□ Offender is a third party non-employee

□ Involves repeated activity by one student against the target

□ Involves repeated activity by more than one student against the target

□ Involves a written, oral or electronic communication

□ Involves a physical act

Describe the act and/or any injury: __________________________________________________________________________________________

□ Involves emotional harm to target

Describe the nature of the harm/effect: __________________________________________________________________________________________

□ Involves damage to target's property

Describe the damage/cost of repair: __________________________________________________________________________________________

□ Target has reasonable fear of harm to self or property

Explain: __________________________________________________________________________________________

□ Offender's actions have created a hostile environment at school for the target or others

Explain: __________________________________________________________________________________________

□ Target's rights at school have been infringed

Explain: __________________________________________________________________________________________

□ Offender's actions have substantially disrupted the educational process or orderly operation of a school

Explain: __________________________________________________________________________________________

CONCLUSIONS

Definitions:

"Bullying" means (A) the repeated use by one or more students of a written, oral or electronic communication, such as cyberbullying, directed at or referring to another student attending school in the same school district, or (B) a physical act or gesture by one or more students repeatedly directed at another student attending school in the same school district, that: (i) Causes physical or emotional harm to such student or damage to such student's property, (ii) places such student in reasonable fear of harm to himself or herself, or of damage to his or her property, (iii) creates a hostile environment at school for such student, (iv) infringes on the rights of such student at school, or (v) substantially disrupts the education process or the orderly operation of a school.

"Bullying" shall include, but not be limited to, a written, oral or electronic communication or physical act or gesture based on any actual or perceived differentiating characteristic, such as race, color, religion, ancestry, national origin, gender, sexual orientation, gender identity or expression, socioeconomic status, academic status, physical appearance, or mental, physical, developmental or sensory disability, or by association with an individual or group who has or is perceived to have one or more of such characteristics;

"Cyberbullying" means any act of bullying through the use of the Internet, interactive and digital technologies, cellular mobile telephone or other mobile electronic devices or any electronic communications;

"Teen dating violence" means any act of physical, emotional or sexual abuse, including stalking, harassing and threatening, that occurs between two students who are currently in or who have recently been in a dating relationship;

"Hostile environment" means a situation in which bullying or offending conduct among students is sufficiently severe or pervasive to alter the conditions of the school climate.

'Harassment' is behavior similar to bullying behavior motivated by prejudice based on real or perceived characteristics, but need not be repeated (single incident may be sufficient if sufficiently). Harassment based upon the following can form the basis of discriminatory harassment:

1. Race

2. Color

3. Religion

4. Ethnicity or national origin

5. Disability

6. Gender/sex

7. Sexual Orientation

8. Gender Identity or expression

"Discrimination" is prohibited by state and federal law in public schools. All students must be provided an equal opportunity to participate in the activities, programs and courses of study offered by public schools without discrimination on account of race, color, sex, gender, gender identity or expression, religion, national origin or ethnicity, sexual orientation, or disability.

"Retaliation" is conduct by a student directed against another student for:

1. Reporting or filing a complaint,

2. Aiding or encouraging the filing of a report or complaint

3. Cooperating in an investigation under this policy

4. Taking action consistent with this policy

Sexual Harassment: Under both Title VII of the Civil Rights Act of 1964 and Title IX of the Educational Amendments of 1972, sexual harassment is considered to be unlawful discrimination on the basis of sex. In addition, discrimination on the basis of sex is prohibited by Connecticut law. Finally, sexual harassment by an individual may constitute a crime or child abuse under Connecticut law and require report to police and/or the Connecticut Department of Child and Families. Harassment must interfere with or limit or deny a student's ability to participate in or benefit from a school's program for a finding of sexual harassment under the law.

"Sexual harassment" is unwelcome conduct of a sexual nature and can take a variety of forms including, but not limited to, unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature, sexual violence (rape, sexual assault, sexual battery, sexual abuse, and sexual coercion) or quid pro quo harassment.

"Gender based harassment" is another form of prohibited sex-based harassment and refers to unwelcome conduct based on an individual's perceived or actual sex, including harassment based upon gender identity or expression or nonconformity with sex stereotypes, and does not necessarily involving conduct of a sexual nature.

1. Finding of policy violation. Yes No

If yes, check all that apply:

 Bullying

 Cyberbullying

 Discriminatory harassment based upon:

 Race or color

 Religion

 Ethnicity or national origin

 Gender identity or expression

 Gender/sex

 Sexual orientation

 Disability

 Retaliation

 Sexual Harassment

2. Notification:

Report of the findings shall be provided to the school principal, to the safe school climate specialist and coordinator for bullying investigations, or to the appropriate district civil rights coordinator for discrimination or harassment and shall be maintained in accordance with district record policies and procedures.

Written findings using FERPA restrictions are mailed to the parent(s)/guardian(s) of the alleged aggressor and alleged target.

Check all that apply:

Target's parent/guardian Date: ______________

Aggressor(s) parent/guardian Date: ______________

Law Enforcement Date: ______________

Department of Children and Families (attach DCF report) Date: _________________

Other (specify)___________________________________ Date: _________________

3. Action(s) Taken:

Interim measures (pending outcome of investigation)

Specify___________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Loss of Privileges Detention Positive Behavioral Interventions Education

Out of School Suspension In-School Suspension Community Service Academic Supports

ExpulsionCounselingOther including system wide responses such as assemblies (specify): _________________________________________________________________________________________

4. Describe Safety Planning: _________________________________________________________________________________________

_________________________________________________________________________________________

5. Referrals (if applicable):

Target:

PPT_______ 504 Meeting ______ SAT______ Other (Specify)__________________________________________________________________________________

Aggressor to:

PPT_______ 504 Meeting ______ SAT______ Other (Specify)__________________________________________________________________________________

6. Follow-up with Target: scheduled for ___________________ Initial and date when completed: ________

7. Follow-up with Aggressor: scheduled for ________________ Initial and date when completed: ________

8.Report forwarded to Superintendent if investigation confirmed violation

Date: ___________________

Signature and Title of Investigator: __________________________________________________________________________________________

Date: ____________________________________________________________________________________


Litchfield Board of Education
Form Developed: 1/22/2019

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