Harassment And Violence Report Form - Independent School District No. 879 printable pdf download

INDEPENDENT SCHOOL DISTRICT NO. 879

HARASSMENT AND VIOLENCE REPORT FORM

General Statement of Policy Prohibiting Harassment and Violence

Independent School District No. 879 maintains a firm policy prohibiting all forms of discrimination. Harassment or violence

against students or employees or groups of students or employees on the basis of race, color, creed, religion, national origin,

sex, age, marital status, familial status, status with regard to public assistance, sexual orientation, or disability is strictly

prohibited. All persons are to be treated with respect and dignity. Harassment or violence on the basis of race, color, creed,

religion, national origin, sex, age, marital status, familial status, status with regard to public assistance, sexual orientation or

disability by any pupil, teacher, administrator or other school personnel, which create an intimidating, hostile or offensive

environment will not be tolerated under any circumstances.

Complainant __________________________________________________________________________

Home Address _________________________________________________________________________

Work Address _________________________________________________________________________

Home Phone _____________________________ Work Phone ____________________________

Date of Alleged Incident(s) _______________________________________________________________

Basis of Alleged Harassment/Violence - circle as appropriate race \ color \ creed \ religion \ national origin \

sex \ age \ marital status \ familial status \ status with regard to public assistance \ sexual orientation \ disability.

Name of person you believe harassed or was violent toward you or another person or group ____________

_____________________________________________________________________________________

If the alleged harassment or violence was toward another person or group, identify that person or group. __

_____________________________________________________________________________________

Describe the incident(s) 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; etc.

(Attach additional pages if necessary.) ______________________________________________________

_____________________________________________________________________________________

Where and when did the incident(s) occur? __________________________________________________

_____________________________________________________________________________________

List any witnesses that 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)

For additional information, please contact Mr. Steven Schauberger, DMS Principal/Human Rights Officer

via email at

sschauberger@delano.k12.mn.us

or phone at 763.972.3365, ext. 2356.

Harassment And Violence Report Form - Independent School District No. 879