09.42811AP,2
STUDENTS
Harassmentl Discrimination. Bullvine. Hazing and/or Retaliation
Complaint Form
Complainant
Parent/Guardian
Home Address
Home Phone
Work Phone
Date(s) of alleged incident(s)
Describe the incident(s) as clearly as possible, including where the incident(s) occurred, what happened a~l
what was done and/or said, when the incident(s) occurred; describe any force that was used (if any) and
describe any physical contact involved (if any). Attach additional pages as
necessary.
Was harassment or discrimination involved in the alleged incident? If so, please cheek:
[] sexual
[] racial [] on the basis of mational origin [] on the basis of disability
[] other type of harassment/discrimination? If other, specify:
Person(s) you believe harassed or discriminated against you
List any witnesses that were present
This complaint is based upon my honest belief that
has bullied and/or harassed me or another person. I hereby certify that the information I have provided in this
complaint is true, correct and complete to the best of my knowledge.
Complainant's Signature
Date
Received By
Date
Assigned To
Assigned By
Date
STUDENTS
09.42811 AP.2
(Continued)
Harassment/Discrimination Report Form
BUILDING LEVEL REPORT
TO:
S uperintendenffSupedntendent Designee
FROM:
Principal
DATE:
RE: Hanassment/Discrimination Complaint at (school) by (name) against (name).
On ~ I was assigned the investigation of the attached Harussmant/Diserimination Report by
against
Conclusion:
Three (3) findings are possible:
[] Substantiated
[] Bullying
[] Harassment/Discrimination:
[] sexual
[] racial [] on the basis of national origin [] on the basis of disability
[] other type of harassment/discrimination? If other, specify:
[] Unable to substantiate (non-disciplinary corrective or protective action warranted)
[] Unsubstantiated
Support for conclusion: (may attach additional information):
ACTION TAKEN (please attach action plan unless unsubstantiated):
Appeal Requested:
Yes
No
***Results and appeals sent to Director of Elementary or Secondary