Harassment Student Complaint Form printable pdf download

Harassment Student Complaint Form

ELEMENTARY SCHOOL STUDENT COMPLAINT FORM – HARASSMENT

If someone at school is making you feel uncomfortable by what they say or do you can

tell an adult, like your teacher, principal, counselor, or anyone else who works at your school.

The person you tell will listen to you and help you with the situation.

1. Your full name: ___________________________________________________________

2. Homeroom: ___________________________________ Grade: ____________________

3. What happened? __________________________________________________________

___________________________________________________________________________

4. Who did this? ____________________________________________________________

5. Did you see someone making someone else uncomfortable? If yes who seemed

uncomfortable? ___________________________________________________________

6. When did this happen? What was the date? _____________________________________

7. What time did this happen?__________________________________________________

8. Where did this happen?_____________________________________________________

9. Did anyone else see what happened? _______________ Who? _____________________

10. What do you think we should do about this? ____________________________________

___________________________________________________________________________

Date you gave this to a school employee (teacher,

principal or other employee):

11. Your Signature:

______________________________

_______________________________________

Harassment Student Complaint Form