Parties Present for Intake Interview:
Name/Position of Investigator:
Date of Contact with Parent/Legal Guardian:
Date Complaint Filed:
Complaint Name (last, first):
Relationship to the target student:
Target Name/Grade (last,first) if not Complainant Statement is taken from alleged target student as well:
Accused Name/Grade (last/first)
Date of Last Alleged Incident:
You are required to cooperate fully with any investigation conducted by the District. If you choose not to cooperate with this investigative process, and that includes answering all questions posed to you, you may subject yourself to disciplinary action, up to and including suspension. Do you understand this?
Yes No
During this interview, or at any point during this investigative process, if you knowingly provide untruthful or inaccurate statements, you may subject yourself to disciplinary action, up to and including suspension. You may not knowingly file a false complaint. Do you understand this?
Yes No
The District may take disciplinary action against any employee or student who is found to have retaliated against a student who has filed a formal complaint or provided statements during a complaint process. An act of retaliation would be in violation of the District’s Anti-Harassment policy and would subject the individual to disciplinary action. Do you understand this?
Yes No
Initials: Date:
You are allowed to discuss this investigation with members of your immediate family, your designated adult staff contact persons and the bullying investigator. You are not allowed to discuss this investigation with anyone else. Please don’t discuss this investigation with friends and other students, even if you plan to name them as witnesses. Please let me make contact with anyone I plan to interview. Please don’t tell them or warn them that I may be speaking with them. Discussions regarding this investigative process will be perceived as an attempt to influence and/or interfere with the District’s investigation, a violation of the code of conduct. Do you understand this?
Yes No
Add as many individual allegations with information about what happened, who is the accused, where the incident occurred, when the incident occurred, and who witnessed the alleged incident, who was told about the alleged incident shortly after it occurred, or who would have information about the alleged incident as are provided by the complainant/target student. Make multiple copies of page three if necessary to capture all allegations
Allegation: What happened?
Who is accused of bullying behavior?
When did this happen?
Where did this happen?
Who witnessed this?
Initials Date
Initials Date
Allegation: What happened?
Who is accused of bullying behavior?
When did this happen?
Where did this happen?
Who witnessed this?
Initials Date
Did you want to add anything else I haven’t asked you about?
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature of Complainant: Date:
Signature of Legal Guardian: Date:
I am aware that I am not to discuss this complaint with anyone other than my parents/legal guardian, my designated adult staff contact persons or the investigator.
Signature of Complainant: Date:
Signature of Legal Guardian: Date:
Initials Date
Approved: January 2007
Reviewed: April/May 2014
Revised: April/May 2014
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