104.E3 - Disposition of Complaint Form

Information Regarding Submission of Complaint:

Complainant (person submitting complaint):

Relationship of Complainant to School/District:

Date of Submitted Complaint:

Alleged Target Name:

Relationship of Complainant to Alleged Target:

Grade/Position of Alleged Target:

Attendance Center Alleged Target:

Date of Alleged Incident:

Location of Alleged Incident:

What method was reportedly used for the alleged bullying and/or harassment? (check all that apply)

☐    Physical

☐    Written

☐    Verbal

☐    Electronic (cyberbullying)

☐    Social/Relational (ostracizing, exclusion)

 

Investigation Summary

Summary of the investigation (add pages as necessary):

 

Did the investigation determine that the incident was targeted and repeated against the alleged student target?

 

Is there a need for an IEP meeting? _____yes  _____no
 

Determination

Founded _____ Unfounded _____

Briefly explain the rationale for that decision:

 

 Authorizing Signature

I agree that all contained herein is true and accurate to the best of my knowledge.

Name (printed):_________________________________________________________

Signature: ______________________________________ Date: ______________________

Title: _____________________________________________________________________