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103.1-E1 - Anti-Bullying/Harassment Complaint Form




Click here to download Policy 103.1-E1 - Anti-Bullying/Harassment Complaint Form

Name of Person Filing Complaint (Complainant):
Relationship of COmplainant to District:
Date of Complaint:
Name of Alleged Victim:
Name of Alleged Bully/Harasser:
Date and Place of Alleged Incident:

Nature of alleged bullying/harassment: (Check all that apply)

  Age   Marital Status   Other - Please speciby below:
  Color   Sex
  Creed   Sexual Orientation
  National Origin   Gender Identity
  Race   Political Party Preference
  Religion   Political Beliefs
  Ancestry   Socioeconomic Status
  Physical Attributes   Familial Status
  Genetic Information   Pregnancy
  Physical/Mental Ability or Disability   Military Status

Description of Misconduct (Attach additional pages if needed):

Name of Witnesses (if any):

Evidence of bullying/harassment or bullying such as letters, photos, etc. (Attach evidence, if possible):

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

Complainant's Signature:

Please return this completed form to:
Equity Coordinator/Title IX Coordinator/Affirmative Action Coordinator:
Mrs. Karla Christian, Chief Officer of Human Resources
319-447-3036 /

Equity Coordinator:
Mr. Nathan Wear, Associate Superintendent
319-447-3028 /

Address: 2999 N 10th Street, Marion, IA 52302
Fax: 319-377-9252

Reviewed: 5/14; 9/16
Revised: 6/20
Related Policy (Code#): 103.1; 103.1-R; 103.1-E2-E3
IASB Reference: 104.E1