Student Harassment Complaint Form printable pdf download

Calhoun County Board of Education

Student / Parent Complaint Form

This form may be used as part of the Board's Complaint / Grievance Procedure by students and parents

who wish to initiate a formal written complaint involving violations of the Board's Policy for Prevention of

Student Harassment, Sexual Discrimination and Harassment Policy, Racial Harassment Policy, or other

violations of law or policy directly affecting the rights of the complaining party.

Date: __________________________ School: _____________________________________________

Name of Student / Complaining Party: ____________________________________________________

Parents: ____________________________________________________________________________

Address: ____________________________________________________________________________

Telephone: Home _____________________________ Cell / Other _____________________________

Does this complaint involve physical violence or the threat of physical violence or injury? ___No ___Yes

Has there been a threat of suicide in connection with this incident / complaint?

___No ___Yes

If yes, please provide additional details.____________________________________________________

____________________________________________________________________________________

Provide a complete description / explanation of the complaint, including the date of the incident on which

the complaint is based, names of students or others responsible or involved in the incident, names of

witnesses, and all other relevant facts. Use the back or attach additional paper as needed.

____________________________________________________________________________

Describe any earlier efforts to resolve this matter or the reasons no such efforts were pursued.

____________________________________________________________________________

What specific remedy or corrective action are you seeking?

____________________________________________________________________________

___________________________________

Student Signature

Parent Signature

Student Harassment Complaint Form