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104.1-E1 - Anti-Bullying/Harassment Complaint Form

 

 

 

Name of Complainant:
Position of Complainant:
Name of Student or Employee Target:
Date of Complaint:
Name of Alleged Harasser or Bully:
Date and Place of Incident(s):

Nature of discrimination or harassment alleged (check all that apply):

  Age   Physical Attribute   Sex
  Disability   Physical or Mental Ability   Sexual Orientation
  Familial Status   Political Belief   Socio-Economic Background
  Gender Identity   Political Party Preference   Other - Please specify below
  Marital Status   Race/Color  
  National Origin/Ethnic Backround/Ancestry   Religion/Creed

Description of Misconduct:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Name of Witness (If Any):
Evidence of harassment or bullying (Letters, photos, etc.) Attach evidence if possible:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

Any other information:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

I agree that all the information on this form is accurate and true to the best of my knowledge.

Signature:
Date:


Reviewed: 5/14; 9/16
Related Policy (Code#): 104.1; 104.1-R; 104.1-E2-E3