Harassment and Violence Report Form
Feel free to contact the appropriate District Human Rights Officer:
ISD728 Elk River Area School District Office
11500 193rd Ave. NW, Elk River, MN 55330

•Tim Caskey, Executive Director of HR - Employees  763/241-3417
      timothy.caskey@isd728.org
•Kari Rock, Asst Superintendent - Secondary  763/241-3523
      kari.rock@isd728.org
•Jamie Nord, Asst Superintendent - Elementary 763/241-3523
      jamie.nord@isd728.org

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Email *
Complainant: *
Home Address: *
Work Address: *
Home/Cell Phone: *
Work Phone: *
Date of alleged incident(s): *
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/
DD
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YYYY
Basis of alleged harassment/violence - select all that apply: *
Required
Name of the person or persons you believe harassed or was violent toward you or another person or group: *
If the alleged harassment or violence was toward another person or group, identify that person or group: *
Where and when did the alleged incident(s) occur? *
List any witnesses that were present: *
Describe the incident(s) as clearly as possible, including such things as what force, if any was used; any verbal statements (i.e., threats, requests, demands, etc); what, if any, physical contact was involved, etc.: *
By submitting this google form you agree to the following statement:     This complaint is filed based on my honest belief that the above mentioned person or group has harassed or has been violent to me or to another person or group. *
A copy of your responses will be emailed to the address you provided.
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