JICFA-EA ©

EXHIBIT

HAZING

(File with a school administrator, the administrator's
supervisor, or a professional staff member)
Additional pages may be attached if more space is needed.

Please print:

Name _____________________________________ Date ______________

Address _______________________________________________________

Telephone _______________________ During the hours of _____________

Another phone where you can be reached ____________________________

E-mail address __________________________________________________

Report/Complaint:

Specify your complaint by stating the problem as you see it. Describe the incident, the participants, and the background to the incident. Be sure to note relevant dates, times, and places.

______________________________________________________________

If there is anyone who could provide more information regarding this, 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 that this information is correct to the best of my knowledge.

_______________________________________ ____________________
Student Date

_______________________________________ ____________________
Administrator or professional staff member Date initial complaint received
receiving initial complaint

The investigating administrator shall give one (1) copy to the complainant and retain one (1) copy for the file.