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104 E1 Anti-Bullying Harassment Complaint Form

104 E1 COMPLAINT FORM (Discrimination, Anti-Bullying, and Anti-Harassment) Date of complaint: _____________________________________________________ Name of Complainant: _____________________________________________________ Are you filling out this form for yourself or someone else (please identify the individual if you are submitting on behalf of someone else): _____________________________________________________ _____________________________________________________ Who or what entity do you believe discriminated against, harassed, or bullied you (or someone else)? _____________________________________________________ Date and place of alleged incident(s): _____________________________________________________ _____________________________________________________ _____________________________________________________ Names of any witnesses (if any): _____________________________________________________ Nature of discrimination, harassment, or bullying 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 In the space below, please describe what happened and why you believe that you or someone else has been discriminated against, harassed, or bullied. Please be as specific as possible and attach additional pages if necessary. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I agree that all of the information on this form is accurate and true to the best of my knowledge. Signature: _____________________________________ Date: __________________________

Date Board Adopted: 11-19-2007

Date Board Reviewed and Updated 10-16-2017