Lemoore Union HSD | E 5131.2 Students
To: School Site Principal
From: Name: _______________________________________________________
Phone Number(s): ____________________________________________________
Name of Person(s) against whom report is made:
Nature of Report: In your own words, please describe the incident(s) that occurred. Please include all names, dates, and places necessary for a complete understanding of the incident(s).
(You may attach additional paper as necessary)
Have you discussed this incident(s) with anyone else?________________________
If so, please list those you have spoken to:
Were there witnesses to the incident(s)? ____________________________________
If so, please list those who were witnesses:
I/We understand that the Superintendent or designee may request further information about this complaint and as such information is available, I/We will provide it upon request.
I/We certify under penalty of perjury that the above documentation is true and correct.
Executed this _________day of _____________, 20_____ at ____________________
Exhibit LEMOORE UNION HIGH SCHOOL DISTRICT
version: August 27, 2015 Lemoore, California