Staff Complaint Form Based On Discrimination, Harassment/sexual Harassment
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2Staff Complaint Form
Based On Discrimination, Harassment/Sexual Harassment,
Hostile Work Environment or Intimidation
Pursuant to Nevada Revised Statutes 388.132 and 388.135 and WCSD Board Policy and Administrative Regulation
4111.3, the Washoe County School District is committed to maintaining a learning environment that is free from
bullying, cyber-bullying, discrimination, harassment, sexual harassment or hostile work environment based on
race, national origin or color, age, disability, religious preference, sex (including non-conformity to gender
stereotypes), sexual orientation, or gender identity or expression. Intimidation or retaliatory acts are prohibited.
This complaint shall remain confidential to the fullest extent allowed by law.
Complainant Information:
Name:
Address:
City
State
ZIP
Home Phone:
Work Phone:
Email:
School or Work Location/Department:
Occupation:
This complaint alleges (check all that apply):
___Discrimination
___Harassment
___Sexual Harassment
___Intimidation
___Retaliation
___Hostile Work Environment
___Bullying
___Cyber-Bullying
On the basis of (check all that apply):
__Race, color or national origin __Age __Disability __Religious preference
__Gender (including non-conformity to gender stereotypes), sexual orientation, or gender identity or expression
__Alleged Violations of NRS 388.135
Subject of Complaint:
Name:
Occupation (if known):
School or Work Location/Department (if known):
Complaint:
Incident(s) occurred or began on or about (date):
Time of Occurrence (approximate is acceptable):
Place of Occurrence (description of area or address). Example: “Room N-99, Anytown High School):
Time and Place that you addressed complaint with supervisor, or reason for not addressing complaint with supervisor:
Description of Incident (Please attach additional information as necessary.):
Please attach any and all related documents necessary to the investigation.
Date: 1/09/12; Rev. A
LEG -F122
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