OJA Referral: Yes No Demographics Target (or alleged target) – Race Gender Disability Status Hispanic / Latino Male None known American Indian / Alaska Native Female IDEA Asian Transgender 504 Plan Native Hawaiian / Pacific Islander or African American White English Proficiency Multiracial Religion Proficient Other: LEP Demographics Bully (or alleged bully) – Race Gender Disability Status Hispanic / Latino Male None known American Indian / Alaska Native Female IDEA Asian Transgender 504 Plan Native Hawaiian / Pacific Islander Black or African American White English Proficiency Multiracial Religion Proficient Other: LEP Signature of Investigator Date
OJA Referral: Yes No Demographics – Target (or alleged target) Race Hispanic / Latino American Indian / Alaska Native Asian Native Hawaiian / Pacific Islander or African American White Multiracial Other: Gender Male Female Transgender Religion Disability Status None known IDEA 504 Plan English Proficiency Proficient LEP Demographics – Bully (or alleged bully) Race Hispanic / Latino American Indian / Alaska Native Asian Native Hawaiian / Pacific Islander Black or African American White Multiracial Other: Gender Male Female Transgender Religion Disability Status None known IDEA 504 Plan English Proficiency Proficient LEP Signature of Investigator Date
Appendix%2009-11-17.docx