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105.1-E4 Discrimination/Anti-Bullying/Anti-Harassment Complaint Form




Click here to download Policy 105.1-E4 - Discrimination/Anti-Bullying/Anti-Harassment Complaint Form

Date of Complaint:
Name of Complainant:

Are you filling out this form for yourself or someone else?
(Please identify the individual if you are submitting this form on behalf of someone else):

Who or what entity do you believe discriminated against, harassed, or bullied you (or someone else):

Date and Place of Alleged Incident(s):
Names of Witnesses:

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

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

In the space below, please describe what happened and why you believe that you or someone else has been discriminated against, harassed, or bullied. Please be as specific as possible and attach additional pages if necessary. ______________________________________________________________________________________________________________

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


Adopted: 10/17
Related Policy (Code #): 105.1; 105.1-R; 105.1-E1-E3, E5-E6