JICK-EA ©

EXHIBIT

STUDENT  VIOLENCE / HARASSMENT / 
INTIMIDATION / BULLYING

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 _________