CSD Student Bullying/ Harassment/ Discrimination Reporting Form
Student, staff, and visitor safety is our number one priority at Cedarburg School District. If you are a student of the District and believe you have been bullied, harassed, and/or discriminated against by an individual on school grounds, report the incident by completing this form.
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Email *
Date *
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Name of Student (Complainant) *
Address *
City, State, Zip Code *
Contact Telephone Number *
Name of individual filing complaint (if different than above)
Position of person filing complaint *
Required
The complaint alleges (check all that apply) *
Required
On the basis of protected class (check all that apply, if any) *
Required
Statement of Complaint. Please describe as best you can exactly what happened to you, or the student on behalf of which this complaint form is submitted, which leads you to believe that you or the student has been bullied, harassed and/or discriminated against.  Include dates; times; locations; the names of everyone who was involved in the bullying, harassment and/or discrimination, including all person(s) who saw or heard what happened; and, all other relevant facts.   If there was more than one incident of bullying, harassment and/or discrimination, please describe each incident separately. *
I  certify that the information I have provided in this complaint is true, correct, and complete to the best of my knowledge. (Name of Person Filing Complaint) *
Date *
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Upon receipt by District personnel or if being submitted by District personnel, this form will be provided to the Building Principal immediately.  Policies 2260, 2260.01, 2266, 5517, 5517.01
Cedarburg School Board Policy Manual: https://go.boarddocs.com/wi/cedar/Board.nsf/Public?open&id=policies 
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