Form Gaba-R - Bullying/harassment/discrimination Complaint Form - Mukwonago Area School District

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Bullying/ Harassment/Discrimination

GABA-R

Complaint Form

Mukwonago Area School District

School/Site: _______________________________

Date of Report:____________________________

Your Name

Names(s) of Harassers(s)/

Complainant: ______________________________

Discriminator(s) ___________________________

Your Address:____

_______________

____________

__________

________________

____________

______

Your Home Telephone Number ____________________

School or Work number_____________________

You are filing a complaint alleging (check one):

Bullying

Harassment

Discrimination

Hazing

BULLYING

•If this is a Complaint regarding Bullying, you are filing a complaint alleging that the bullying behavior was (check

type(s)):

What Is Bullying?

Bullying is a deliberate or intentional behavior using words or actions, intended to cause fear,

intimidation or harm. Bullying may be repeated behavior and involves an imbalance of power.

Physical

Indirect

Verbal

Kicking

Gossiping

Name Calling

Pushing

Spreading rumors

Teasing

Harming Property

Ostracizing

Other:_____________

Other:______________

Humiliating

Cyberbullying

Insulting Gestures

Other:______________

Name of targeted student(s) if different from person reporting:________________________________

Names of Other Witnesses:____________________________________________________________

Date of Incident:_____________________

Time of incident

______am _____pm

Location of Incident:_________________________________________________________________

HARRASSMENT/DISCRIMINATION/HAZING

•If this is a Discrimination Complaint, you are filing a complaint alleging discrimination under one or more of the

following areas:

What Is Harassment?

Behavior towards students based in whole or part on sex, race, color, religion, national origin, ancestry,

creed, pregnancy, marital or parental status, sexual orientation, or physical, mental, emotional, or learning disability which substantially interferes

with a students’ school performance or creates an intimidating, hostile, or offensive school environment.

Discrimination:

Treatment or consideration based on class or category rather than individual merit.

Racism can be defined as:

An act or series of acts directed at a person/group or their property because of the color of their skin

or their racial or ethnic origin.

Hazing:

Intentionally or recklessly engaging in acts which endanger physical health or safety of a student for the purpose of initiation or

admission into affiliation with any organization.

Sex

Creed

Mental Disability