Harassment Student Complaint Form (Page 3 of 3) in pdf

Harassment Student Complaint Form Page 3

SECONDARY SCHOOL STUDENT COMPLAINT FORM – HARASSMENT

1. Your full name: ___________________________________________________________

2. School: __________________________ Homeroom: __________ Grade: ___________

3. Describe the conduct you found objectionable, including what force, if any was used; verbal

statements (threats, requests, demands, etc.); what if any physical contact was involved

(additional sheets may be attached):

4. The name of the person or persons alleged to be harassing you:

_________________________________

5. If the alleged unlawful harassment was directed against another person identify the other

person:

________________________________________________________________________

6. The date of the incident described in #3: _______________________________________

7. The approximate time of the incident’s occurrence, as described in #3: _______________

8. The location of the incident described in #3:

________________________________________________________________________

9. The names of any witnesses to the incident described in #3:

________________________________________________________________________

10. Please briefly identify the actions you would like to be taken by the school district in

correcting the matter you have identified:

11. Date this complaint was submitted:

Your Signature:

______________________________

___________________________

NOTE: If you are unable to provide all of the information requested on this form, as for

example, if you do not know the name or names of the person whose behavior you find

objectionable, please file the report and leave that area blank.

RETURN YOUR COMPLAINT TO YOUR PRINCIPAL

Harassment Student Complaint Form Page 3