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Name of Person Filing Complaint (Complainant):
Relationship of Complainant to District:
Date of Initial Complaint:
Name of Alleged Victim:
Grade or Position and Building of Alleged Victim:
Date and Place of Alleged Incident:
Name and Grade/Position of Alleged Bully/Harasser:
Nature of alleged bullying/harassment (Check all that apply):
| Age | Marital Status | ||
| 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 | ||
| Other - Please Specify | |||
Summary of Investigation (Attach an additional sheet, if needed):
I agree that all of the information is accurate and true to the best of my knowledge.
Signature of Equity Coordinator:
Date:
Reviewed: 5/14; 9/16; 3/23
Revised: 6/20
Related Policy: 103.1; 103.1-R; 103.1-E1-E2
IASB Reference: 104-E(3)