Download - Student Complaint Form
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7/31/2019 Student Complaint Form
1/2
CARROLLTONFARMERSBRANCHINDEPENDENTSCHOOLDISTRICT
StudentComplaintFormInstructionsforreportingincidentsof
BULLYING,SEXUALHARASSMENT,andDATINGVIOLENCE
Acounselororadministratorwhoreceivesareportofbullying,sexualharassment,datingviolence,or
sexualviolence
will
address
the
following
issues
with
the
student
who
was
the
victim
of
the
reported
behaviorsinaprivatemeetingbeforeassistingthestudentincompletingtheComplaintForm.
Your Right to File a Complaint
ThepolicyofCarrolltonFarmersBranchISDisthatallstudentsandemployeesbefreefrombullying,
sexualharassment,anddatingviolence.Allchargesofbullying,sexualharassment,anddatingviolence
aretobetakenveryseriouslybystudents,faculty,staff,administration,andparents/guardians.The
Districtwillmakeeveryreasonableefforttohandleandrespondtoeverychargeandcomplaintfiledby
studentsandemployeesinafair,thorough,andjustmanner.Everyreasonableeffortwillbemadeto
protectthedueprocessrightsofallvictimsandallallegedperpetrators.
Instruction: Usethisformtoreportbullying,sexualharassment,anddatingviolencesothatschool
officialsmayinvestigateandtakeappropriateactionstoincreaseyoursafety.
Completetheform,providingasmuchdetailedinformationaspossiblesothatthecomplaintmaybe
properlyinvestigated.
Itisimportantthatyoureportthefactsasaccuratelyandcompletelyaspossibleandthatyoucooperate
fullywiththepersonsdesignatedtoinvestigatethecomplaint.
Wheretofile: Complaintformswillbeavailablefromanycounselororadministrator.
Confidentiality: Toconductthisinvestigationinaconfidentialmanner,theschoolwilldisclosethe
contentsofyourcomplaintonlytothosepersonswhohaveaneedtoknowofyourcomplaint.Insigning
thecomplaintform,youauthorizetheschooltodiscloseasneededtheinformationyouhaveprovided,
andmayinthefutureprovide,regardingyourcomplaint.Yourcomplaintformwillnotbeshowntothe
allegedperpetrator.
Retaliation
prohibited:
Retaliation
against
a
person
who
files
a
formal
complaint
is
strictly
prohibited
andisgroundsfordisciplinaryaction,includingbutnotlimitedtodetention,suspension,andexpulsion.
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7/31/2019 Student Complaint Form
2/2
CARROLLTONFARMERSBRANCHINDEPENDENTSCHOOLDISTRICT
StudentComplaintFormforreporting
BULLYING,SEXUALHARASSMENT,
AndDATINGVIOLENCE
Name:_____________________________________________StudentID:________________________
Grade:_______Date:______________ Time:___________ School:____________________________
Please answer the following questions about the most serious incident:
Listthenameoftheallegedperpetrator(s)ofbullying,sexualharassment,ordatingviolence:
_____________________________________________________________________________________
Relationshipbetweenyouandtheallegedperpetrator:
_____________________________________________________________________________________
Describetheincident:
_____________________________________________________________________________________
_____________________________________________________________________________________
Whenandwheredidithappen?__________________________________________________________
Werethereanywitnesses:[ ]yes [ ]no
Ifyes,who?
_____________________________________________________________________________________
IsthisthefirstIncident: [ ]yes [ ]no
Ifno,howmanytimeshasithappenedbefore?
_____________________________________________________________________________________
Otherinformation,includingpreviousincidentsorthreats:
_____________________________________________________________________________________
_____________________________________________________________________________________
Studentorparentdeclinestocompletethisform:
Initial:_____________________ Date:_________________