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N ebo School District maintains a firm policy

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STUDENT VICTIM INVESTIGATION FORMS
Form #3, Response Form page 1 of 1 Version 10/2018
N
ebo School District maintains a firm policy prohibiting all forms of bullying, discrimination, and harassment.
SCHOOL:
RESPONDENT INFORMATION:
Name:
Home Address:
Home/Cell Phone:
Work Phone:
Email:
INCIDENT(S) INFORMATION:
Date(s) / Time(s) of alleged incident(s):
Name(s) of persons involved in incident(s):
Location of incident(s):
Name(s) of other witness(es):
Provide a detailed response to the complaint against you. This includes admitting or denying each allegation made
and telling your version of the facts (attach additional pages if necessary):
I hereby represent that the information provided herein is true, correct, and complete to the best of my knowledge.
Signature:
Date:
If the respondent is unable or unwilling to complete and sign this form, provide the following information and sign
below.
Name of person completing form:
Title:
Reason respondent did not complete form:
Signature:
Date:
Confidentiality & Retaliation
In order to protect the privacy interests of individuals and to ensure the integrity of the investigation, this complaint and
investigation are confidential. You are hereby directed to refrain from speaking of or disseminating relevant facts or
information concerning this matter to others. You are also directed to refrain from retaliation against the person who
made the complaint. Disciplinary action may be imposed for violation of this directive.
For School Use Only
Maintain original at school in investigation file. Submit copy to Coordinator of Student Services
BULLYING, DISCRIMINATION, AND HARASSMENT
RESPONSE FORM
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N ebo School District maintains a firm policy

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Completed 7 December 2021

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