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Discrimination, Harassment, Bullying, Hazing and Violence Report Form
Edina Public Schools maintains policies prohibiting discrimination, harassment, bullying, hazing and violence. These policies can be found on the district's website or obtained from a district administrator. All persons are to be treated with respect and dignity. Please use this form to report incidents of discrimination, harassment, bullying, hazing or violence.
Appendix I to Policies 401, 402, 413, 514, 521, 522, 526, 528
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Person completing report *
Home address *
Work address *
Home phone *
Work Phone *
Date of alleged incident(s) *
Basis of Alleged Harrasment/Violence - check as appropriate: *
Required
Name of person(s) you believe harassed, bullied or was violent toward you or another person *
If the alleged harassment or violence was toward another person(s), identify that person(s) *
Where and when did the incident(s) occur? *
Describe the incident(s) as clearly as possible, including such things as: what force, if any, was used; any verbal statements (e.g. threats, requests, demands); what, if any, physical contact was involved; or other relevant information. *
List any witnesses to the incident(s) *
By typing my name below, I acknowledge that the information I have provided in this form is true, correct, and complete to the best of my knowledge and belief. *
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