ADOPTED:      08/16/2010

                                                                                                                                                                                411.1 Exhibit

School District of Prairie Farm

Student Harassment, Bullying, and Cyber-Bullying Complaint Form

Name of complainant:                                                                                                                                                                              

Where did or is the incident(s) occur(ring) (building, grounds)?                                                                                                         

When did or is the incident(s) occur(ring)?  Date:                                                                  Time:                                                    

Was or is anyone else present at the time the incident(s) occurred or is occurring?                                                                       

Who was or is involved in the incident(s)?                                                                                                                                             

What happened or is happening (nature of complaint)?                                                                                                                    

How does complainant want the incident(s) or complaint resolved?                                                                                               

Name of person providing information for the form:                                                                                                                         

Name of person completing form:                                                                                                  Date:                                              

Signature of complainant: ________________________________________     Date: _____________________        

Action taken:

                      By whom:                                                                                                               Date:                                                     

Cross Reference:                 411 - Equal Educational Opportunity

                                                411.1- Student Harassment, Bullying, and Cyber-Bullying

                                                411.1 Rule- Student Harassment, Bullying, and Cyber-Bullying Complaint Procedure

                                                510 - Policy Rule

Legal Ref.:                            Sections 111.31, 118.01(2)(d)8, 118.13, 118.164, 118.195,

                                                118.20, 120.13(1), 947.0125, 947.013, 948.51(2), Wisconsin Statutes

                                                PI 9, Wisconsin Administrative Code

                                                Title IX, Education Amendment of 1972

                                                Title VI of the Civil Rights Act of 1964

                                                Section 504 of the Rehabilitation Act of 1973

                                                Americans with Disabilities Act

                                                Equal Protection Clause of the Fourteenth Amendment