104.E1 Anti-Bullying/Harassment Complaint Form

POSTED: July 23, 2024

Code No. 104.E1 ANTI-BULLYING/HARASSMENT COMPLAINT FORM

 

Name of complainant:
Position of complainant:
Name of student or employee target:
Date of complaint:
Name of alleged harasser or bully: 
Date and place of incident or incidents: 
Nature of Discrimination or Harassment Alleged (Check all that apply)

   Age Physical Attribute Sex
   Disability Physical/Mental Ability Sexual Orientation
   Familial Status Political Belief Socio-economic Background
   Gender Identity Political Party Preference Other – Please Specify:
   Marital Status Race/Color   
National Origin/Ethnic Background/Ancestry Religion/Creed

 

Description of misconduct: 
Name of witnesses (if any): 
Evidence of harassment or bullying, i.e., letters, photos, etc. (attach evidence if possible):  
Any other information:
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature:
Date:        /         /