File:  GBA-F/JFHA-F

 

Report of Harassment

 

 

Name of Complainant:        

 

For Students, School Attending:

 

For Employees, Position:

 

Address and Phone Number:

 

 

Date(s) of Alleged Incident(s) of Harassment:

 

Name of person(s) you believe harassed you or others.

 

If the alleged harassment was toward another, please identify that person:

 

Please describe in detail the incident(s) of alleged harassment, including where and when the incident(s) occurred.  Please note any witnesses that may have observed the incident(s).  Attach additional pages if necessary.

 

 

Please describe any past incidents that may be related to this complaint.

 

 

What action has been taken by the school administration?

 

 

State precisely the reason(s) why you are dissatisfied with any prior action on this matter.

 

 

I certify that the information provided in this report is true, correct and complete to the best of my knowledge:

 

_______________________________________________________________

Signature of Complainant                                                                       Date

 

 

Complaint Received By:      _________________________________________

                                                (Principal or Compliance Officer)                Date

 

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