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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 (List Specific Examples):
_________________________________________________________________________
_________________________________________________________________________
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 Nondiscrimination Coordinator:
Date:
Reviewed: 5/14; 9/16; 3/23
Revised: 6/20; 9/25
Related Policy: 103.1; 103.1-R; 103.1-E1-E2
IASB Reference: 104-E(3)