Complaint Report
Report of Violence, Threat of Violence, Harassment, Intimidation, and/or Bullying
This form is used to report violence, threats of violence, harassment, intimidation and/or bullying that is believed to have occurred during the current school year on school property, at a school sponsored activity, or on a school bus. If this is a sexual harassment complaint, please contact the Title IX coordinator.
School Name *
Your answer
Student Name *
Your answer
Date of Incident *
MM
/
DD
/
YYYY
Time *
Time
:
Location of Incident *
Your answer
Person(s) making this report *
Required
Reported Victim(s) *
Your answer
Reported Perpetrator(s) *
Your answer
Description of conduct leading to complaint *
Your answer
Requested resolution/Relief/action: *
Your answer
I believe the incident in question was motivated by the following characteristic(s): *
Required
The incident resulted in a threat of suicide by the victim: *
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