INDEPENDENT SCHOOL DISTRICT NO. 81
 
INDEPENDENT SCHOOL DISTRICT NO. 81
RELIGIOUS, RACIAL, ETHNIC OR SEXUAL HARA.SSMENT AND VIOLENCE REPORT FORM
General Statement of Policy Prohibiting Harassment
Independent School District No. 81 maintains a firm policy prohibiting all forms of discrimination. Religious, racial, ethnic, sexual, or general harassment or violence against students or employees is discrimination. All persons are to be "treated with respect and dignity. Sexual violence, sexual advances or other forms of harassment by any pupil, teacher, administrator or other school personnel, which create an intimidating, hostile or offensive environment will not be tolerated. Complainant._________________________________________________ Home Address _______________________________________________
Work Address _______________________________________________
Home Phone _____________________________________ Work Phone _____________________________
Date of Alleged Incident(s) _____________________________________ Circle" as appropriate: sexual \ racial \ ethnic \ religious \ hazing \ intimidation (e.g. bullying) \ general
Name of person you believe harassed or was violent toward you or another person. _____________________
If the alleged harassment or violence was toward another person, identify that person. ___________________
Describe the incident(s) as dearly 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; etc. (Attach additional pages if necessary.) ________________________________________________________________________ ________________________________________________________________________________________
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Where and when did the incident(s) occur? _____________________________________________________
List any witnesses who were present. _________________________________________________________
This complaint is filed based on my honest belief that ______________________________________has harassed or has been violent to me or to another person. I hereby certify that the information I have provided in this complaint is true, correct and complete to the best of my knowledge and belief.
____________________________________________________ ________________________
(Complainant Signature) ` (Date)

Received by _________________________________________ Date ___________________