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Nebo School District maintains a firm policy prohibiting

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STUDENT VICTIM INVESTIGATION FORMS
Form #2, Complaint Form page 1 of 2
Version 10/2018
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]:
BULLYING, DISCRIMINATION, AND HARASSMENT
COMPLAINT FORM
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STUDENT VICTIM INVESTIGATION FORMS
Form #2, Complaint Form page 2 of 2
Version 10/2018
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
The Coordinator of Student Services will be promptly notified of this complaint. The Building Administrator will determine whether to
conduct a site-level or District-level investigation. If additional information from you is needed, you will be contacted for a follow-up
interview. The investigation will also include interviews with, and written statements from, the victim, the person against whom the
complaint is made, witnesses, and others identified as having pertinent information.
The investigator will consider all the evidence and will make findings of fact and conclusions as to whether any District policies have
been violated. In the case of policy violation, disciplinary action may be taken against the respondent. Other actions may be taken
to address the effects on the victim and the school environment. To the extent legally permissible, the victim and the respondent
will be notified of these decisions.
Confidentiality
The investigation will be conducted in a reasonably confidential manner. However, witnesses and others with pertinent information
may need to be made aware of the investigation and sufficient facts to elicit their verbal/written statements. The investigator will take
measures to protect confidentiality of the victim and the accused, including directing all witnesses to refrain from disseminating
information related to the complaint and investigation.
You should also keep the complaint and investigation confidential. Do not attempt to conduct your own parallel investigation or discuss
the facts of your complaint with others.
No Contact
You should avoid contact with the accused. This includes written, electronic, verbal, and in-person contact. If contact with the accused
is unavoidable in the school, please notify the investigator.
Office for Civil Rights
In addition to filing a complaint with the District, you may also contact the U.S. Department of Education, Office for Civil Rights, 1244
Speer Boulevard, Suite 310, Denver, CO 80204-3582; Telephone No. 303-844-5695; Fax No. 303-844-4303; TDD No. 877-521-2172;
Email OCR.Denver@ed.gov.
For School Use Only
Maintain original at school in investigation file. Submit copy to Coordinator of Student Services
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Completed 7 December 2021

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