Anti-bullying/Harassment Complaint Form
Your name: *
Your answer
Today's Date *
MM
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DD
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Have you asked them to stop? *
Have you asked them to stop? *
*Selecting "No" will not disqualify your submission to start an investigation.
Have you spoken with the teacher/sponsor at that time and asked for ? *
*Selecting "No" will not disqualify your submission to start an investigation.
Date of Incident *
MM
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DD
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YYYY
Name of alleged harasser: *
Your answer
Date and place of incident(s): *
Your answer
Description of incident(s): *
Your answer
Name of witnesses (if any): *
Your answer
Method of bullying/harassment (check all that apply) *
Required
Please identify each of the following 18 categories for which you feel to have been a reason for being bullied or harassed (check all that apply): *
Required
Location of Incident (check all that apply): *
Required
There are four criteria to help determine bullying: Does this incident place you under reasonable fear of harm to yourself or your property? *
Does this have a substantially detrimental effect on your physical or mental health? *
Do you feel this interferes with your academic performance? *
Does this affect your ability to participate in or benefit from the services, activities, or privileges provided by our school? *
If any of the above criteria are not met, there could still be a case of harassment and/or an issue the school can help you with. If this is the case, please submit this form. **Protection Clause: If you turn in a form, you areprotected from any retaliation from the alleged harasser.
**Truth Disclosure: In submitting this form, you are stating the truth and realize that there are consequences fror filing a false claim.
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