CEM - Challenging Behavior Reporting Form

Challenging Behavior Reporting Form

This form is not required by law or policy but serves as a model challenging behavior reporting form that local and regional boards of education may adapt and adopt.

Instructions

This form is for students, parents or guardians of students enrolled in the school, and school employees to report any alleged challenging behavioral incidents. Challenging behavior is behavior that negatively impacts school climate or interferes, or is at risk with interfering, with the learning or safety of a student or the safety of a school employee. This form should also be used to report alleged bullying incidents, meaning: unwanted and aggressive behavior among children in grades kindergarten to twelve, inclusive, that involves a real or perceived power imbalance.

Complete this form electronically, or in writing, or go to your school climate specialist (principal, vice principal, or other certified administrator) who will assist you with completing this form. All completed reports require a response from the school climate specialist, and every student, parent or guardian, and school employee who completed this form will receive a copy of the “Response Process(es) Notification Form” describing the action steps taken, within three (3) school business days after an assessment has been completed.

The school climate specialist will assess the facts of a challenging behavior incident and complete the "Response Process(es) Notification Form” (located on page 5 of this document). A confirmation of receipt of the “challenging behavior reporting form” will be provided to the individual who completed this form within three (3) school business days, and the behavioral assessment will be finalized within a reasonable amount of time.

Name of Person Completing Report: (student reports may be anonymous)*

Answer required for "Name of Person Completing Report: (student reports may be anonymous)"

Check here for any student who would like to submit anonymously.

Answer required for "Check here for any student who would like to submit anonymously."

Submit anonymously

I am a: *

Answer required for "I am a: "

Student

Parent and/or Guardian

School Employee

Email*

Answer required for "Email"

Phone Number*

Number Required

Contact me by:*

Answer required for "Contact me by:"

Phone

Was this previously reported to any school employee prior to this report? If yes, identify to whom, when, and what was reported?*

Answer required for "Was this previously reported to any school employee prior to this report? If yes, identify to whom, when, and what was reported?"

Where did the incident occur?*

Answer required for "Where did the incident occur?"

Check any boxes that apply*

Answer required for "Check any boxes that apply"

On school property

At a school-sponsored activity or off school property

Electronic communication, internet, and social media

On a school bus

On the way to/from school

Outside of school

Other:

Approximate date of incident (if know):

Answer required for "Approximate date of incident (if know):"

Please describe what happened and include the student's name in the description?*

Answer required for "Please describe what happened and include the student's name in the description?"

Of the following statement(s) check any that may describe or include what happened:

Answer required for "Of the following statement(s) check any that may describe or include what happened:"

Teasing, name-calling, intimidating, or threatening, in person or through electronic communication

Spreading rumors or gossip

Hitting, kicking, shoving, spitting, hair pulling, or throwing something or other acts of physical aggression

Making intimidating, and/or threatening gestures or remarks

Getting another person to do any of the behaviors listed above

Unwanted contact of a sexual nature (verbal, non-verbal, physical)

Do you believe that the reported instance(s) of challenging behavior was in reference to a student’s perceived or actual age, ancestry, color, learning disability, marital status, intellectual disability, national origin, physical disability, mental disability, race, religious creed, sex, gender identity or expression, sexual orientation, and status as a veteran? If so, why?

Answer required for "Do you believe that the reported instance(s) of challenging behavior was in reference to a student’s perceived or actual age, ancestry, color, learning disability, marital status, intellectual disability, national origin, physical disability, mental disability, race, religious creed, sex, gender identity or expression, sexual orientation, and status as a veteran? If so, why?"

If known, provide the name(s) of any witness(es) of the alleged incident:

Answer required for "If known, provide the name(s) of any witness(es) of the alleged incident:"

This form does not modify or eliminate any rights or obligations under state and federal laws, including, any constitutional and civil rights protections, or any applicable policies and procedures or collective bargaining agreements. All students' private and personal information will remain confidential throughout this process, subject to any wavier rights or disclosure responsibilities as permitted or required by law.

Please note: when a student exhibits challenging behavior, our priority is to ensure the safety of the students and the school, and to work with the student(s) to prevent the recurrence of such behavior, including making amends for any challenging behaviors that occurred. Federal law protects the privacy of each student. Therefore, you cannot be provided with any specific information concerning the student alleged to have engaged in the challenging behavior.

Please fix the highlighted areas below before submitting.

CEM - Challenging Behavior Reporting Form