STUDENT HARASSMENT, HARASSMENT AND/OR BULLYING COMPLAINT FORM

The purpose of this form is to inform the District of an incident or series of incidents of bullying and/or harassment so we can investigate and take appropriate steps.  If you feel unsafe, or if you are a parent and your child feels unsafe, fill out this form, but we urge you to speak directly with the school principal as soon as possible so we can address your concerns.

Student or Employee Name:_________________________________________   

Grade:_____________        School:___________________________________

Describe the incident(s).  Please include when and where it happened.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List the name(s) of the individual(s) accused of bullying and/or harassment.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Were there any witnesses?  ___Yes    ____No   If yes, please list the names of the individual(s).

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I certify that all statements on this form are accurate and true to the best of my knowledge.*

_____________________________________        _____________________

Signature *                                                    Date

Please attach any supporting documentation (i.e., copies of emails, notes, photos, etc.).

Return this form to:  the School Principal

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 and only to the extent necessary to conduct an investigation prior to taking any formal disciplinary action. This form will not be shown to the accused student(s)/staff.

*  To best execute the investigation of the complaint, the complaint should be signed and the complainant identified; however, neither is required and you may submit this report anonymously.