Harassment/Discrimination Report

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I am a...*

Today's Date*

Name*

First Last

Contact Phone Number*

Date of Occurrence(s)*

School/Location where the incident occurred*

The incident involved*

Harassment
Discrimination

The incident was based on*

(Click all that apply)

Name of the person(s) you believe harassed or discriminated against you or another*

First	Last

If alleged incident was towards another person, identify that person(s)

First	Last

Describe the incident as clearly as possible, including such things as what force, if any, was used, any verbal statements (i.e. threats, requests, demands, etc.), what, if any, physical contact was involved.*

When and where did the incident(s) occur?*

List any witnesses who were present

First	Last

What would you like to see happen?

Acknowledgement of Correct Information*

I declare that the foregoing information is true and correct. I understand that neither I, nor anyone involved in the incident, are to retaliate against the other party. I also have the right not to be retaliated against by the other party involved in this incident. If I feel threatened in any way, or have concerns, I will contact the person in charge of this complaint. I hereby certify the information I have provided in this complaint is true, correct, and complete to the best of my knowledge.

Signature*

First Last

Entering your name here indicates digital signature

Date Signed