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)
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Age |
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Physical Attribute |
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Sex |
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Disability |
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Political Belief |
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Sexual Orientation |
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Familial Status |
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Race/Color |
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Socio-economic Background |
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Marital Status |
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Religion/Creed |
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Other – Please Specify: |
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National Origin/Ethnic Background/Ancestry |
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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: / /