0115 Exhibit Student Harassment and Bullying Prevention and Intervention

STUDENT HARASSMENT AND BULLYING PREVENTION AND INTERVENTION

STUDENT 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, or if your child feels that way, fill out this form, but we urge you to speak directly with the building principal and/or calling the building principal as soon as possible so we can address your concerns.

Student Name:_______________________________  Student ID:____________________________

Grade:_____________            School:_________________________________________  

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.

Download the Exhibit Student Harassment and Bullying Prevention and Intervention PDF