Form Sts0114a - Bullying/harassment Complaint Form (Page 2 of 2) in pdf

FOR ADMINISTRATIVE USE ONLY:

Attach any supporting documentation/evidence of the investigation.

Use a separate form for each alleged perpetrator.

Alleged Information  1

offense



repeat offender/alleged

Name: ___________________________________ Grade ______ School _______________________________

Parent Information (if student) _______________________________ Contact Number ___________________

Address ___________________________________________________________________________________

INITIAL PARENT CONTACT DOCUMENTATION (MUST BE BY PHONE AND IN WRITING)

Parent contact of alleged perpetrator: By phone date: _____________ By writing date: ___________  US Mail

 Electronic

Parent contact of alleged victim:

By phone date: _____________ By writing date: ___________  US Mail

 Electronic

Investigation Details:

Summary of Investigative action (Attach additional pages if needed)

__________________________________________________________________________________________________

 Bullying Behavior Substantiated

 Bullying Behavior Unsubstantiated

 Harassment Behavior Substantiated

 Harassment Behavior Unsubstantiated

Was Bullying/Harassment behavior related to:

 Race?

 Sex?

 Disability?

 Not Applicable

 Religion?

 Sexual Orientation?

Action Taken: (describe) ___________________________________________________________________________

__________________________________________________________________________________________________

Resulted in School Discipline Referral

 Yes

 No

If yes, Referral # _____________________

 Investigation turned over to Law Enforcement (complete below)

Name of Law Enforcement personnel notified: ____________________________________________________________

Agency ________________________________ ID # ____________________________ Date/Time _________________

Case # _________________________________

Administrator/Designee Signature: ____________________________________________ Date ____________________

PARENT CONTACT AT CONCLUSION OF INVESTIGATION (MUST BE BY PHONE AND IN WRITING)

Parent contact of alleged perpetrator: By phone date: _____________ By writing date: ___________  US Mail

 Electronic

Parent contact of alleged victim:

By phone date: _____________ By writing date: ___________  US Mail

 Electronic

ALL COMPLETED INVESTIGATIONS (Substantiated & Unsubstantiated) MUST BE SENT TO DIRECTOR OF STUDENT SERVICES

Rev. 10/27/15

STS0114A Pg 2 of 2

Form Sts0114a - Bullying/harassment Complaint Form Page 2

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