Bullying Complaint Form
STUDENT VIOLENCE/HARASSMENT/INTIMIDATION/BULLYING COMPLAINT FORM
Anonymous complaints will NOT be accepted: however, the administration endeavors to maintain confidentiality to the fullest possible extent.
Date *
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DD
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YYYY
First Name *
Your answer
Last Name *
Your answer
Email Address *
Your answer
Primary Phone Number *
Your answer
Alternative Phone Number
Your answer
Address 1 *
Your answer
Address 2
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Select school where reported bullying is taking place: *
Person alleged to be the aggressor (bullying)? *
Your answer
Specify your complaint by stating the problem as you see it. Describe the incident, the participants, the background to the incident, and any attempts you have made to solve the problem. (Be sure to include all relevant sates, times, and places) *
Your answer
If there is anyone who could provide more information regarding this complaint, please list name(s), address(es), and telephone number(s). *
Your answer
Indicate what you think can and should be done to solve the problem. (Be as specific as possible) *
Your answer
Please be advised that reprisal by any student or staff member directed toward a student or employee related to the reporting of a case of bullying or suspected bullying shall not be tolerated, and the individual(s) will be subject to the disciplines set out in applicable District policies and administrative regulations. Please be aware that knowingly submitting false reports shall subject students to disciplinary action up to long term suspension or expulsion. *
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