Completion of this form will initiate an investigation of the alleged incident of bullying or harassment
outlined in this form. Please provide sufficient information to permit a meaningful investigation. All information
will be confidential except for that which must be shared as part of the investigation. Submission of a good faith or
complaint or report of bullying or harassment will not affect the complainant or reporter’s future employment,
grades, learning, or working environment or work assignment. By signing above, you are verifying that your
statements are true and accurate to the best of your knowledge.

Bullying means any severe or pervasive physical or verbal act of conduct, including communications
made in writing or by means of an electronic act directed towards one or more pupils that has or can
be reasonably predicted to have the effect of one or more of the following:

A. Placing a reasonable pupil in fear of harm to that pupil’s person or property
B. Causing a reasonable pupil to experience a substantially detrimental effect on their mental
health.
C. Causing a reasonable pupil to experience substantial interference with their academic
performance.
D. Causing a reasonable pupil to experience substantial interference with their ability to participate
in or benefit from the services, activities or privileges provided by a school.

Ed Code 234-234.5