Goleta Union School District
Harassment/Bullying
Student Complaint Form

Instructions: This form may be submitted by a student being harassed/bullied, or who has witnessed someone else being harassed bullied. All submissions will be reviewed by the office of Special Services.
Your name
School
Date and time of harassment/bullying
MM
/
DD
/
YYYY
Time
:
Name of person who was bullied or harassed
Name of person who was bullying or harassing
Have you reported the bullying or harassment to an adult?
Has this been an ongoing offense? (Occurring more than once over a long period of time)
Were there any witnesses? (If so Whom?)
Nature of Complaint:
Explain what happened.
Submit
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