Report of Discrimination/Harassment/Abuse

Name of Complainant:

For Students, School Attending and Grade:

For Employees, List Position, Location, and Telephone Number:

Home Address and Telephone Number:

Date(s) of Alleged Incident(s) of Discrimination/Harassment/Abuse:

Name of person(s) you believe discriminated against/harassed/abused you or others:

If the alleged discrimination/harassment/abuse was toward another, please identify that person:

Please describe in detail the incident(s) of alleged discrimination/harassment/abuse, including where and when the incident(s) occurred. Please name any witnesses that may have observed the incident(s). Attach additional pages if necessary.

Please describe any past incidents that may be related to this complaint.

I certify that the information provided in this report is true, correct, and complete to the best of my knowledge:

________________________________________

Signature of Complainant Date

Complaint Received By: _____________________________

(Principal) Date

_____________________________

(Compliance Officer) Date