104.E1 Anti-Bullying/Harassment Complaint Form

Code No. 104E1

ANTI-BULLYING/HARASSMENT 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):

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 addtional 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: _________________

Approved:  02/26/14
Reviewed:
Revised: 5/15/24