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: _____________________________________________________________________
