BURRILLVILLE SCHOOL DEPARTMENT BULLYING, SEXUAL HARASSMENT, DATING VIOLENCE, AND SEXUAL VIOLENCE COMPLAINT FORM
Please use this form to report incidents of bullying, harassment, dating violence & sexual violence
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Name of person filling out the report: *
Date(s) of Alleged Incident(s): *
Persons/Parties Involved: *
Please list the name(s) of students and/or adults involved. Please list one name per line.
Description of Event (s) *
When and where did the event happen? *
Were there any witnesses? *
If yes, what are their names?
Please list the name(s) of any witnesses. Please list one name per line.
Is this the first incident? *
If no, how many other times has it happened before?
Other information including previous incidents or threats:
Please add any additional information about previous incidents or threats
I certify that all the statements made in this complaint are true and complete. Any intentional misstatement of fact will subject me to appropriate discipline. I authorize
school officials to disclose the information I provided only as necessary in pursuing the investigation. *
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