REPORT FORM FOR COMPLAINTS OF UNLAWFUL HARASSMENT

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

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