Harassment And/Or Bullying Complaint Form

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The purpose of this form is to inform the district of an incident or series of incidents of bullying and/or harassment so we can investigate and take appropriate steps. If you feel unsafe, if your child/student feels that way, or if you are a witness to bullying, please fill out this form. We also urge you to speak directly with the building principal by calling the main office of the school as soon as possible so we can address your concerns. Exhibit 0115-E

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Student Name: *

School: *

Potsdam LA

Potsdam AAK

Potsdam HS

其他：

Grade: *

Describe the incident(s). Please include when and where it happened. *

List the name(s) of the individual(s) accused of bullying and/or harassment. *

Were there any witnesses? *

Yes

必填

If yes, please list the names of the individual(s).

I certify that all statements on this form are accurate and true to the best of my knowledge. *

I Agree

I Disagree

必填

Today's Date: *

YYYY

Please deliver any supporting documentation to your building principal (i.e., copies of emails, notes, photos, etc.).

Note on confidentiality: In order to investigate the complaint, the district will disclose the content of the complaint only to those persons who have a need to know. This form will not be shown to the accused student(s)/staff.

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