Code No. 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:

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
National Origin/Ethnic Background/Ancestry	Religion/Creed

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:
Parent Signature ______________________ (Optional)
Date:	/ /