Complaint Form – Student Bullying, Harassment, Intimidation Contact Info Name: Address: Telephone: Other Phone Number: Preferred time to be contacted: Email Address: Complaint Form I wish to submit a complaint against Name of person(s): Specify your complaint by stating the problem as you see it. Describe the incident, the participants, background to the incident, and any attempts you have made to solve the problem. Please include all relevant dates, times, and places. Additional pages may be attached if necessary. Enter the details below: Please upload any additional information if needed: If there is anyone who could provide more information regarding this complaint, please list name(s), address(es), and telephone number(s). Please provide the details below: Projected Solution Indicate what you think can and should be done to solve the problem. Be as specific as possible. Please enter your solution below: Signature I certify this information is correct to the best of my knowledge (sign by typing your initials). Signature of Complainant: Date:
