Gooding Joint School District No. 231

STUDENTS                                                                                                                            3295F

Hazing, Harassment, Intimidation, Bullying, Cyber Bullying, Menacing

HARASSMENT COMPLAINT FORM

School                                                                                              Date                                          

Student’s/Complainant’s Name                                                                                                        (If you feel uncomfortable leaving your name, you may submit an anonymous report, but  please understand that an anonymous report will be much more difficult to investigate.

We assure you that we’ll use our best efforts to keep your report confidential.)

Who was responsible for the harassment or incident(s)?                                                                 

Describe the incident(s).                                                                                                                   

Date(s), time(s), and place(s) the incident(s) occurred.                                                                   

Were other individuals involved in the incident(s)?        yes             no

If so, name the individual(s) and explain their roles.                                                                      

Did anyone witness the incident(s)?         yes          no

If so, name the witnesses.                                                                                                                

Is there any evidence of the harassment (i.e. letters, photos)        yes                  no

If so, please describe.                                                                                                                      

Did you take any action in response to the incident?       yes             no

If yes, what action did you take                                                                                                     

Were there any prior incidents?        yes             no

If so, describe any prior incidents                                                                                                  

I agree that all of the information on this form is accurate and true to the best of my knowledge.

Signature of complainant                                                                                                                

Signatures of parents/legal guardian                                                                                                

Cross Reference:  3210                      Uniform Grievance Procedure

Legal References: 20 U.S.C. § 1681, et seq. Title IX of the Educational Amendments 34 CFR Part 106

I.C. § 67-5909       Acts Prohibited

Policy History:

Adopted on: July 17, 2012 Revised on: