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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:
Names of Witnesses (if any):
In the space below, please describe what happened and why you believe that you or someone else has been bullied/harassed. Please be as specific as possible and attach additional pages if necessary.
______________________________________________________________________________
______________________________________________________________________________
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:
Date:
Please return this completed form to:
Equal Employment/Nondiscrimination Coordinator/Title IX Coordinator:
Karla Christian, Chief Human Resources Officer
319-447-3036 / kchristian@Linnmar.k12.ia.us
Nondiscrimination Coordinator:
Nathan Wear, Associate Superintendent
319-447-3028 / nathan.wear@Linnmar.k12.ia.us
Special Education/Student Services Nondiscrimination Coordinator:
Anne Faber, Executive Director of Student Services
319-730-3663 / anne.faber@Linnmar.k12.ia.us
Address: 3556 Winslow Road, Marion, IA 52302
Fax: 319-403-8008
Reviewed: 5/14; 9/16; 3/23
Revised: 6/20; 10/23; 9/24; 9/25
Related Policy: 103.1; 103.1-R; 103.E2-E3
IASB Reference: 104-E(1)