0115E

STUDENT 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 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 School Counseling Services, or a Building Level Title IX Coordinator as soon as possible so we can address your concerns.

Student Name:______________________________________ Student ID: _________________   

Grade:_____________        School:________________________________________________

Contact Information: _____________________________________________________________

1. List the name(s) of the individual(s) accused of bullying and/or harassment (use additional sheets of paper if necessary).

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. 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.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. 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: ____________

4. Is the harassment continuing?  ___Yes    ____No  
5. 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:

6. Has the student previously complained about or provided information (verbal or written) to the District about bullying, harassment or discrimination or related events?

___Yes    ____No  

If yes, when and to whom was the complaint made or information provided to?

___________________________________________________________________________

7. 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

_____________________________________          _____________________________

Signature                                                               Date

Preferred contact method (please select one) and contact details:

Phone           ____________________________

Email            ____________________________

US 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 School 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:  November 2022