Goleta Union School District
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.
Goleta Family School
Date and time of harassment/bullying
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:
Physical (hitting, kicking, pushing, biting, etc)
Verbal (spreading rumors, social isolation/leaving out)
Insults about: ( race/color/gender/ disability/national origin)
Cyber bullying (comments, notes, emails, texts)
Explain what happened.
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