HARASSMENT AND/OR BULLYING COMPLAINT FORM
The purpose of this form is to document an incident or series of incidents of bullying and/or
harassment so we can investigate and take appropriate steps. For parents, if you or your child
feels that they are unsafe, speak directly with the principal/Dignity Act coordinator in your
building immediately and then fill out this form.
Student Name Student ID:
Grade: Home District: Building:
Date of Incident:
Approximate time of incident: Location(s) of incident:
Describe the incident(s).
List the name(s) of the individual(s) accused of bullying and/or harassment.
List the name(s) of other possible victims:
Were there any witnesses or bystanders? Yes No If yes, please list the names of the
individual(s).
What is your relationship to the student?
Parent
Teacher
Student Peer
Self
Other (
please indicate)
I certify that all statements on this form are accurate and true to the best of my knowledge.
Printed Name
Signature
Date
Return this form to your building principal/Dignity Act Coordinator
