104.E1 - Anti-Bullying/Harassment Complaint Form

Name of complainant:  ____________________________________________________________

Position of complainant:  __________________________________________________________

Name of student or employee target:  _________________________________________________

Date of complaint:  _______________________________________________________________

Name of alleged harasser or bully:  ___________________________________________________

Date and place of incident or incidents:  _______________________________________________
_______________________________________________________________________________

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:  ____________________