Code No. 104E1
ANTI-BULLYING/HARASSMENT COMPLAINT FORM
Name of complainant: ________________________________________ Date: _________________
Position of complainant: ____________________________________________________________
Name of student or employee harmed: ___________________________________________________
Name of alleged harasser or bully: _____________________________________________________
Date and place of incident or incidents: _________________________________________________
Nature of Discrimination or Harassment Alleged (Check all that apply)
__ Age __ Physical Attribute __ Sex
__ Disability __ Physical/Mental Ability __ Sexual Orientation
__ Familial Status __ Political Belief __ Socio-economic Background
__ Gender Identity __ Political Party Preference __ Other - Please Specify:
__ Marital Status __ Race/Color ______________________
__ Religion/Creed __ Background/Ancestry __ National Origin/Ethnic
Description of misconduct: __________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Name of witnesses (if any): __________________________________________________________
_________________________________________________________________________________
Evidence of harassment or bullying, i.e., letters, photos, etc. (attach evidence if possible): _________
_________________________________________________________________________________
_________________________________________________________________________________
Any other information: ______________________________________________________________
_________________________________________________________________________________
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: __________________________________________________ Date: _________________
Assisting Staff Member Signature (if appropriate): ________________________________________
Please complete this form and submit it to the building administrator and send a copy to the District Superintendent’s Office.
Approved: 02/26/14
Reviewed:
Revised: 04/14/2021