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.

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:_________________