0115 Exhibit 1 Student Harassment and Bullying Prevention and Intervention

HARASSMENT AND BULLYING PREVENTION AND INTERVENTION

STAFF 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 and/or harassment so we can investigate and take appropriate steps. If you feel unsafe, fill out this form, but we urge you to speak directly with the building principal and/or one of the Title IX Compliance Officers or calling the building principal or the Title IX Compliance Officers: Assistant Superintendent of Secondary Education at 631-434-2498, Assistant Superintendent of Elementary Education at 631-434-2496, Assistant Superintendent of Special Services 631-434-2401 or School Personnel Officer at 631-434-2331 as soon as possible so we can address your concerns.

Name:_____________________________________________________________________________

Building:___________________________________________________________________________

Describe the incident(s). Please include when and where it happened.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List the name(s) of the individual(s) accused of bullying and/or harassment.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Were there any witnesses? ___Yes ____No If yes, please list the names of the individual(s).

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I certify that all statements on this form are accurate and true to the best of my knowledge.

_________________________________________ ______________________________

Signature Date

Please attach any supporting documentation (i.e., copies of emails, notes, photos, etc.).

Return this form to: Building Principal

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.

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