Nebo School District maintains a firm policy prohibiting all forms of bullying, discrimination, and harassment. SCHOOL: VICTIM INFORMATION: Name: Home Address: Home/Cell Phone: Work Phone: Email: INCIDENT(S) INFORMATION: Check the box(es) to indicate the type of conduct you are complaining of: Bullying/Cyber-Bullying Discrimination Harassment Hazing Retaliation Check the box(es) to indicate the basis of the conduct: Race/Color/National Sex/Gender Religion Disability N/A or None Origin Date(s) / Time(s) of incident(s): Name(s) of alleged respondent(s): Location of incident(s): Name(s) of witness(es): Describe the incident(s) as clearly as possible, including what was said (threats, requests, demands, etc.), whether any physical contact occurred, and what force was used (attach additional pages if necessary): Describe the harm caused by the incident(s) described above, including any hostile school environment, or other adverse effects on your education (attach additional pages if necessary): Describe the remedy you seek, including any assistance you may need to address the harm described above (attach additional pages if necessary). [Please note that seeking a particular remedy does not confer authority on the victim to determine the discipline imposed on the alleged respondent. All remedies, including any disciplinary action, are within the exclusive authority and sole discretion of the School District]: This complaint is based on my honest belief that I have been bullied, discriminated against, or harassed as described above. I hereby represent that the information provided herein is true, correct, and complete to the best of my knowledge. Victim’s signature: Date: If the victim is unable or unwilling to complete and sign this form, provide the following information and sign below. Name of person completing form: Title: Reason victim did not complete and sign form: Signature: Date: Information for Persons Filing a Complaint Overview of Investigative Process
Nebo School District maintains a firm policy prohibiting all forms of bullying, discrimination, and harassment. SCHOOL: VICTIM INFORMATION: Name: Home Address: Home/Cell Phone: Work Phone: Email: INCIDENT(S) INFORMATION: Check the box(es) to indicate the type of conduct you are complaining of: Bullying/Cyber-Bullying Discrimination Harassment Hazing Retaliation Check the box(es) to indicate the basis of the conduct: Race/Color/National Origin Sex/Gender Religion Disability N/A or None Date(s) / Time(s) of incident(s): Name(s) of alleged respondent(s): Location of incident(s): Name(s) of witness(es): Describe the incident(s) as clearly as possible, including what was said (threats, requests, demands, etc.), whether any physical contact occurred, and what force was used (attach additional pages if necessary): Describe the harm caused by the incident(s) described above, including any hostile school environment, or other adverse effects on your education (attach additional pages if necessary): Describe the remedy you seek, including any assistance you may need to address the harm described above (attach additional pages if necessary). [Please note that seeking a particular remedy does not confer authority on the victim to determine the discipline imposed on the alleged respondent. All remedies, including any disciplinary action, are within the exclusive authority and sole discretion of the School District]: This complaint is based on my honest belief that I have been bullied, discriminated against, or harassed as described above. I hereby represent that the information provided herein is true, correct, and complete to the best of my knowledge. Victim’s signature: Date: If the victim is unable or unwilling to complete and sign this form, provide the following information and sign below. Name of person completing form: Title: Reason victim did not complete and sign form: Signature: Date: Information for Persons Filing a Complaint Overview of Investigative Process
JDC-F2.docx