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0115E - STUDENT HARASSMENT, HARASSMENT AND/OR BULLYING COMPLAINT FORM
0000 - PHILOSOPHY
0115E STUDENT HARASSMENT, HARASSMENT AND/OR BULLYING COMPLAINT FORM
Last Updated Date: 08/03/2021
Revisions History: 08/03/2021, 03/11/2021, 06/14/2012
Related Policies & Documents: 0115, 0115R
The purpose of this form is to inform the District of an incident or series of incidents of bullying or harassment so we can investigate and take appropriate steps.
The District prohibits bullying and harassment of students on the basis of actual or perceived race, color, weight, national origin, ethnic group, religion, religious practice, disability, sex, sexual orientation, and gender identity or gender expression.
If the student feels unsafe at school, fill out this form, but we urge you to speak directly with the Building Principal, or the Director of Guidance and Counseling Services, or a Building Level Title IX Coordinator as soon as possible so we can address your concerns.
Student Name:______________________________________ Student ID: __________
Contact Information: _____________________________________________________
- List the name(s) of the individual(s) accused of bullying and/or harassment (use additional sheets of paper if necessary).
- Describe the incident(s). Please include when and where it happened. Please use additional sheets of paper if necessary and attach any relevant information, documents or evidence. If this form is completed by someone other than the student, if possible, please have the student describe the situation in their own words.
- I believe the harassment is based on the student’s (check all that apply):
____ race ____ ethnic group ____sex
____ color ____ religion ____ sexual orientation
____ weight ____ religious practice ____gender identity or expression
____ national origin ____disability ____other: ____________
- Is the harassment continuing? ___Yes ____No
- Please list the name (if known) of anyone who witnessed the incident or who may have related to the complaint.
The following question is optional, but may help the District’s investigation:
- Has the student previously complained about or provided information (verbal or written) to the District about bullying, harassment or discrimination or related events?
If yes, when and to whom was the complaint made or information provided to?
- If you have retained legal counsel and would like the District to work with them, please provide their contact information.
I certify that all statements on this form are accurate and true to the best of my knowledge.
Name Relationship to student
Preferred contact method (please select one): phone, email, mail, in person
Please attach any supporting documentation (i.e., copies of emails, notes, photos, etc.).
Return this form to:
Building Principal, or Director of Guidance and Counseling Services, or a Building Level Title IX Coordinator
Note on confidentiality:
In order to investigate the complaint, the District will disclose the content of the complaint only to those persons who have a need to know. This form will not be shown to the accused student(s)/staff.
Reaffirmed: July 29, 2021