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 _________