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:  ____________________

 

 

Approved   07/19/07                              
Reviewed  10/18/21                                                           
Revised _08/10/09_