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103.1-E1 - Anti-Bullying and Anti-Harassment Complaint Form

Click here to download the Anti-Bullying/Anti-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
  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

Description of Misconduct (Attach additional pages if needed):

Name of Witness (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:
Date:

Please return this completed form to:
Equity Coordinator/Title IX Coordinator/Affirmative Action Coordinator:
Karla Christian, Chief Officer of Human Resources
319-447-3036 / kchristian@Linnmar.k12.ia.us

Equity Coordinators:
Nathan Wear, Associate Superintendent (Secondary Level)
319-447-3028 / nathan.wear@Linnmar.k12.ia.us

Bob Read, Associate Superintendent (Elementary Level)
319-447-3016 /
bread@Linnmar.k12.ia.us

Special Education/Student Services Equity Coordinator:
Melissa Frick, Executive Director of Student Services
319-447-3663 / melissa.frick@Linnmar.k12.ia.us

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


Reviewed: 5/14; 9/16; 3/23
Revised: 6/20; 10/23
Related Policy: 103.1; 103.1-R; 103.1-E2-E3
IASB Reference: 104.E(1)