Anti-Bullying/Harassment Complaint Form

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This form is to be used to file complaints of harassment, sexual harassment, or bullying. This is NOT to be used for complaints of teasing. Remember that for bullying to be present the actions must meet the following three criteria. 1) There is a pattern of negative behaviors established, often including repeated aggression. 2) The behavior is a deliberate intent to harm or disturb the target/victim. 3) An imbalance of power is established.

Email *

Record my email address with my response

Grade Level *

Preschool

Kindergarten

1st Grade

Name of complainant:

(Your Name) First name, Last Name

Name of alleged harasser or bully:

First name, Last name

Indicate the category of behavior you think the complaint would fit within. Select the one that is the best fit.

Harassment will be defined as conduct of a verbal or physical nature that is designed to embarrass, distress, agitate, disturb or trouble persons on the basis of age, color, creed, national origin, race, religion, marital status, sex, sexual orientation, gender identity, physical attributes, physical or mental ability or disability, ancestry, political party preference, political belief, socioeconomic status or familial status.

Sexual harassment may include unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature.

Bullying to be present the actions must meet the following three criteria. 1) There is a pattern of negative behaviors established, often including repeated aggression. 2) The behavior is a deliberate intent to harm or disturb the target/victim. 3) An imbalance of power is established.

Unacceptable teasing will include spreading rumors or gossip, ridicule, verbal abuse, public shunning or private humiliation and embarrassment.

Date, time and place of incident:

example: hallway by room 207 between first and second period

Name of witnesses (if any):

ex. John Doe and Jane Doe

Description of misconduct.

Please included as much information as possible. Details and sequence of events are very useful in the investigation process.

Any other information: *

Evidence of misconduct.

When applicable insert link to evidence. This can be done by creating a Google document of the item and allowing "sharing" with those that have access to the link.

Relationship to incident.

Select the best match

Target of behavior

Witness

Third party information. (You have heard about the incident and believe it to be true.)

Other:

Date of complaint form completion.

Example format: 00/00/0000

I understand that being interviewed about the filed complaint is a necessary component of the investigation process.
*

Yes

Other:

I agree that all of the information on this form is accurate and true to the best of my knowledge.*

Knowingly filling a false complaint MAY result in discipline actions.

Yes

Other:

Submit

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