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 discriminated against, 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 discriminated against, 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: __________________________
Definitions
For the purposes of this policy, the defined words shall have the following meaning:
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“Electronic” means any communication involving the transmission of information by wire, radio, optic cable, electromagnetic, or other similar means. “Electronic” includes but is not limited to communication via electronic mail, internet-based communications, pager service, cell phones, and electronic text messaging.
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“Harassment” and “bullying” mean any repeated and targeted electronic, written, verbal, or physical act or conduct toward an individual that creates an objectively hostile school environment that meets one or more of the following conditions:
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Places the individual in reasonable fear of harm to the individual’s person or property.
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Has a substantial detrimental effect on the individual’s physical or mental health.
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Has the effect of substantially interfering with the individual’s academic or career performance. Has the effect of substantially interfering with the individual’s ability to participate in or benefit from the services, activities, or privileges provided by a school.
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“Volunteer” means an individual who has regular, significant contact with students.
