502.10E1 - Complaint Form

Code No. 502.10E1

 

COMPLAINT FORM

(Anti-Bullying/Anti-Harassment)

 

Date of complaint: 

_____________________________________________________

Name of Complainant: 

_____________________________________________________

Are you filling out this form for yourself or someone else (please identify the individual if you are submitting on behalf of someone else):

_____________________________________________________

 

_____________________________________________________

Who or what entity do you believe harassed or bullied you (or someone else)?

_____________________________________________________

Date and place of alleged incident(s): 

_____________________________________________________

 

_____________________________________________________

 

_____________________________________________________
 

Names of any witnesses (if any): 

  

_____________________________________________________

 

In the space below, please describe what happened and why you believe that you or someone else has been harassed or bullied. Please be as specific as possible and attach additional pages if necessary. 

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I agree that all of the information on this form is accurate and true to the best of my knowledge. 

Signature: _____________________________________ Date:  __________________________