Student Violence, Bullying, Intimidation, Harassment

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1 Case 4:74-cv DCB Document Filed 10/01/14 Page 159 of 229 Student Violence, Bullying, Intimidation, Harassment COMPLAINT FORM (To be filed with any School District employee who will forward this document to the principal or principal s designee, the site director and Charlotte Brown-Dept. of Student Equity) Please Print Name Date Address Telephone During the hours of Another phone where you can be reached Address I wish to complain against: Name of person(s) Specify your complaint by stating the problem as you see it. Describe the incident, the participants, the background to the incident, and any attempts you have made to solve the problem. Be sure to include all relevant dates, times and places. Additional pages may be attached if necessary. JICK-E1 Revised: Appendix VI-24 p. 1

2 Case 4:74-cv DCB Document Filed 10/01/14 Page 160 of 229 If there is anyone who could provide more information regarding this complaint, please list name(s), address(es) and telephone number(s). Name Address Telephone Number The projected solution: Indicate what you think can and should be done to solve the problem. Be specific as possible. I certify this information is correct to the best of my knowledge. Signature of Complainant Date Document Received by Date Investigation Official Date JICK-E1 Revised: Appendix VI-24 p. 2

3 Case 4:74-cv DCB Document Filed 10/01/14 Page 161 of 229 PRINCIPAL S REPORT ( to be sent to the site director and Charlotte Brown-Dept. of Student Equity) Findings: Determination: Corrective Action: JICK-E1 Revised: Appendix VI-24 p. 3

4 Case 4:74-cv DCB Document Filed 10/01/14 Page 162 of 229 Student Violence, Bullying, Intimidation, Harassment Complaint Form - Spanish Violencia Estudiantil, Hostigamiento, Intimidacion, Acoso FORMULARIO DE QUEJA (Para presentarse a cualquier empleado del Distrito Escolar que remitirá este documento al director o persona designada por el director, el director del sitio y a Charlotte Brown del Departamento de Equidad Estudiantil) Por favor escriba con letra de molde Nombre Fecha Dirección Teléfono Durante el siguiente horario Otro número donde se le puede localizar Dirección de correo electrónico Deseo presentar una queja contra: Nombres de la persona (s) Especifique su queja indicando el problema como usted lo ve. Describa el incidente, los participantes, los antecedentes del incidente y cualquier intento que usted haya hecho para resolver el problema. Asegúrese de incluir todas las fechas, horas y lugares pertinentes. Se pueden adjuntar páginas adicionales si es necesario. JICK-E1 Revised: Appendix VI-24 p. 4

5 Case 4:74-cv DCB Document Filed 10/01/14 Page 163 of 229 Student Violence, Bullying, Intimidation, Harassment Complaint Form - Spanish Si hay alguna persona que podría proporcionar más información sobre esta queja, por favor, indique su nombre(s), dirección(es) y números de teléfono. Nombre Dirección Número de Teléfono La solución prevista: Indique lo que usted cree que se puede y se debe hacer para resolver el problema. Sea lo más específico posible. Certifico que esta información es correcta según mi leal saber y entender. Firma del Denunciante Fecha Documento recibido por Fecha Oficial de la investigación Fecha JICK-E1 Revised: Appendix VI-24 p. 5

6 Case 4:74-cv DCB Document Filed 10/01/14 Page 164 of 229 Student Violence, Bullying, Intimidation, Harassment Complaint Form - Spanish REPORTE DEL DIRECTOR (que se enviará al director del sitio y a Charlotte Brown del Departamento de Equidad Estudiantil) Conclusiones: Determinación: Acción Correctiva: JICK-E1 Revised: Appendix VI-24 p. 6

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