Bullying and Harrasment Form

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

Address

What School or Location are you usually at?

Date of Alleged Incident(s)

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

I agree

Today's Date

Must contain a date in M/D/YYYY format

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

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