JICK-EA ©

EXHIBIT

STUDENT BULLYING / HARASSMENT /
INTIMIDATION

COMPLAINT FORM
(To be filed with any School District employee who will forward this
document to the principal or the principal's designee)

Please print:

Name ______________________________________ Date __________________

Address _____________________________________________________________

Telephone _____________ Another phone where you can be reached ____________

During the hours of ____________________________________________________

E-mail address ________________________________________________________

I wish to complain against:

Name of person(s) ______________________________________________________

Specify your complaint by stating the problem as you see it. Describe the incident, the participants, the background to the incident, and any attempts you have made to solve the problem. Be sure to include all relevant dates, times, and places. Additional pages may be attached if necessary.

_____________________________________________________________________

If there is anyone who could provide more information regarding this complaint, please list name(s), address(es), and telephone number(s).

Name Address Telephone Number

_____________________________________________________________________

The projected solution

Indicate what you think can and should be done to solve the problem. Be as specific as possible.

_____________________________________________________________________

I certify this information is correct to the best of my knowledge.

Signature of Complainant ______________________________ Date ____________

Document received by _________________________________ Date ____________

Investigating official ___________________________________ Date ____________