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Bullying and Harrasment Form

Required

SAPS Letter Head

INDEPENDENT SCHOOL DISTRICT NO. 834
BULLYING, HARASSMENT, or VIOLENCE REPORT FORM

Independent School District No. 834 maintains a firm policy prohibiting all forms of discrimination.  This policy strictly prohibits bullying, harassment, or violence against students or employees or groups of students or employees on the basis of race, color, creed, religion, national origin, sex, age, marital status, familial status, status with regard to public assistance, sexual orientation, or disability (Protected Class).  All persons are to be treated with respect and dignity. Harassment or violence on the basis of Protected Class by any pupil, teacher, administrator, or other school personnel, that create an intimidating, hostile, or offensive environment will not be tolerated under any circumstances.

 

 

Complainant Namerequired
First Name
Middle (optional)
Last Name
Email Address
Phone Number
Address
What School or Location are you usually at?
Date of Alleged Incident(s)
Basis of Alleged Bullying or Harassment/Violence
Name of person you believe bullied or harassed or was violent toward you or another person or group.required
First Name
Middle (optional)
Last Name
If the alleged bullying or harassment or violence was toward another person or group, identify that person or group.
Describe the incident(s) as clearly as possible, including such things as: what force, if any, was used; any verbal statements (i.e., threats, requests, demands, etc.); what, if any, physical contact was involved; etc.0 / 2500
WHERE did the incident(s) occur?
WHEN did the incident(s) occur?
MM/DD/YYYY
List any witnesses who were present
This complaint is filed based on my honest belief that the person named below has harassed or has been violent to me or to another person or group. required
First Name of person who bullied others
Last Name
I hereby certify that the information I have provided in this complaint is true, correct, and complete to the best of my knowledge and belief.required
Today's Date
Must contain a date in M/D/YYYY format