Complainant: ________________________________________________________________
Home Address:_______________________________________________________________
Home Phone: ________________________________________________________________
School Building:______________________________________________________________
Date of Alleged Incident(s):_____________________________________________________
Alleged harassment was based on: (circle those that apply)
Race Color National Origin
Gender Age Disability
Religion Sexual Orientation Sexual Harassment
Other:______________________
Name of person you believe violated the district’s unlawful harassment
policy:
____________________________________________________________________________
If the alleged harassment was directed against another person, identify
the other person:
____________________________________________________________________________
Describe the incident as clearly as possible, including what force, if
any, was used; verbal statements (i.e. threats, requests, demands, etc.);
what, if any, physical contact was involved. Attach additional pages if
necessary:______________________________________________ ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
When and where incident occurred:________________________________________________
List any witnesses who were present:______________________________________________
____________________________________________________________________________
This complaint is based on my honest belief that _____________________
has harassed me or another person. I certify that the information I have
provided in this complaint is true, correct and complete to the best of
my knowledge.
_____________________________ __________________
Complainant’s Signature Date
_____________________________ __________________
Received By Date |