Form Sts0114a - Bullying/harassment Complaint Form
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2ST. LUCIE PUBLIC SCHOOLS
Bullying/Harassment Complaint Form
This report MUST be completed to file a complaint relating to an incident of alleged bullying (for the purpose of this form, bullying
encompasses bullying, harassment, and discrimination) and submitted to the Administrator/Designee of the victim’s school, area, or
district location.
VICTIM FULL NAME:
SCHOOL/OFFICE LOCATION
RACE
GENDER
GRADE
AGE
Student
Male
School Employee
Female
Other
ALLEGED PERPETRATOR FULL NAME:
SCHOOL/OFFICE LOCATION
RACE
GENDER
GRADE
AGE
Student
Male
School Employee
Female
Other
Has similar behavior of alleged been observed in the past directed at the same person? Yes
No
** If more than one alleged, complete separate form for each.
ADMINISTRATOR/DESIGNEE of VICTIM’S SCHOOL/OFFICE LOCATION:
TODAY’S DATE
DATE OF MOST RECENT BEHAVIOR
TIME OF MOST RECENT BEHAVIOR
LOCATION OF MOST RECENT BEHAVIOR
Description of Bullying/Harassment Behavior (Include in detail who, what, where, when, how)
Attach additional pages if necessary.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
List all witness names, grade level, and school. (Attach list if necessary)
1. _________________________________________ Gr. ____ Age ___ School _____________________________
2. _________________________________________ Gr. ____ Age ___ School _____________________________
3. _________________________________________ Gr. ____ Age ___ School _____________________________
4. Please attach additional witness information
List evidence of bullying/Harassment behavior (threat or message - written or electronic): – Attach if possible
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
To the best of my knowledge, all of the information on this form is true and accurate. I am aware that false reporting is a criminal offense.
Signature of Person Filing this complaint: ___________________________________________ Date:________________
Print Name: ____________________________________
Check and print name here if someone other than complainant assisted in completing this form._____________________________________________________
Or
Check here if you want to remain anonymous, and omit identifying information about yourself.
Please note: the School Board may not take formal disciplinary action based solely on an anonymous complaint (see Section 1006.147(4)(f), Fla. Stat.), and
it may not accept an anonymous complaint against an employee (see Section 1012.31(1)(b), Fla. Stat.)
Name/Title of person receiving form
Date received
Time received
Thank you. The investigation will be initiated within 2 school days.
If you suspect IMMEDIATE danger exists, please contact law enforcement.
Rev. 10/27/15
STS0114A Pg 1 of 2
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