QXJjaGl2bzpyZWd1bGFy
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
QXJjaGl2bzpyZWd1bGFy
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: |
/ / |