Northwest Local School District H.I.B. Form
Harassment, Intimidation or Bullying
Complaint Form
05-17-07

A student, parent, or guardian may file a complaint (this form) of harassment, intimidation or bullying pursuant to Board policy. The complaint must be specific as the the actions giving rise to the suspicion of harassment, intimidation or bullying. Complete this form and hit submit.

For purposes of this policy, the term “harassment, intimidation or bullying” means any intentional written, verbal, electronic or physical act toward another particular student more than once and the behavior: (1) causes mental or physical harm to the other student; and (2) is sufficiently severe, persistent or pervasive that it creates an intimidating, threatening or abusive educational environment for the other student.

The form will go directly to Dustin Gehring, Assistant Director of Student Services who will forward it directly to the principal or assistant principal. If you do not hear anything within 48 hours of submitting the form, please call Dustin Gehring at 923-1000 ext 3907.

Your Name *
Your answer
Your Address *
Your answer
Your Phone Number *
Your answer
Your Email Address *
Your answer
Your Student's School *
Your answer
All Persons Involved (List both aggressor and victim). Grade level also helps if applicable. *
Your answer
Time and Place of Situation(s): On campus? Off campus? Particular class? Outside of school hours? Etc. *
Your answer
Specifically describe the conduct or incident(s) giving rise to the suspicion of harassment, intimidation, or bullying. *
Your answer
Number of such incidents *
Your answer
Target of above described conduct *
Your answer
Student or staff witnesses
Your answer
Electronic Signature and Date: *
Your answer
Submit
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