This form is to be used by students and/or their parents only after discussing the basis for the complaint with the Principal/designee.
Name _________________________________________ Date _____________________
Address _______________________________________________________________
_______________________________________________________________
Telephone (Home)_______________________ (School or Work)___________________
Status of person filing complaint (check one):
________ High School Student or Parent
________ Middle School Student or Parent
________ Elementary School Student or Parent
Reason(s) for Complaint:
Statement of Complaint (include type of harassment charged and the specific incident(s) in which it occurred):
What happened (including the specific nature of the complaint)?
When did it happen?
Day _____________________
Date _____________________
Time _____________________
Where did it happen?
Who was involved?
Were there any witnesses?
Relief requested:
Signature _____________________________________________________
Date ________________________________________
I (circle one) agree / do not agree that my name may be
disclosed to the person against whom this complaint is being filed. I
understand that if I do not agree to this disclosure, it may be impossible to
process or investigate this complaint and the complaint may be dismissed. Your
name will not be disclosed if there is no compelling reason to disclose it or
if you do not consent to such disclosure.
Signature of complainant ______________________________________________________
Date complaint filed _______________________________________
Submit signed complaint to the District Administrator. The person receiving the complaint will sign, date, and number the complaint. One copy will be sent to the school or department affected by the complaint.
Signature of person receiving complaint __________________________________________
Date received ________________________________________
Complaint number ________________________________________
Complaint authority:
12/21/2004 pw