Policy 104-E(1): Anti-Bullying/Harassment Policy
COMPLAINT FORM
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):
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Age |
Physical Attribute |
Sex |
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Disability |
Physical/Mental Ability |
Sexual Orientation |
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Familial Status |
Political Belief |
Socio-economic Background |
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Gender Identity |
Political Party Preference |
Other – Please Specify: |
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Marital Status |
Race/Color |
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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:__________________________
Case Law References Description
Morse v. Frederick 551 U.S. 393 (2007)
Approved: April 3, 2023
Reviewed: April 3, 2023
Revised: April 3, 2023