CARROLLTONFARMERSBRANCHINDEPENDENTSCHOOLDISTRICT

StudentComplaintFormInstructionsforreportingincidentsof
BULLYING,SEXUALHARASSMENT,andDATINGVIOLENCE

Acounselororadministratorwhoreceivesareportofbullying,sexualharassment,datingviolence,or
sexualviolencewilladdressthefollowingissueswiththestudentwhowasthevictimofthereported
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.

Retaliationprohibited:Retaliationagainstapersonwhofilesaformalcomplaintisstrictlyprohibited
andisgroundsfordisciplinaryaction,includingbutnotlimitedtodetention,suspension,andexpulsion.

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:_________________