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