104.E1 Anti-Bullying/Harassment Complaint Form

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
• 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:

Updated 2-18-2019     Reviewed 7-25-2022