Personnel Harassment Complaint Form printable pdf download

DEKALB COUNTY SCHOOL DISTRICT

1701 Mountain Industrial Boulevard

Stone Mountain, Georgia 30083-1027

PERSONNEL COMPLAINT FORM

This form is to be used to file Complaints in accordance with GAE(2), GAE(3) and GAEB, or for general stakeholder complaints

Please check applicable categories:

[ ] ADMINISTRATOR/SUPERVISORY POSITION

[ ] CERTIFIED

[ ] NON-CERTIFIED/CLASSIFIED EMPLOYEE

[ ] INFORMAL RESOLUTION CONFERENCE – Informal Early Intervention Discussion to resolve workplace disputes. This request

must be filed within ten (10) days after the date on which the cause giving rise to the Complaint is known.

[ ] LEVEL 1 / FORMAL COMPLAINT – Presentation of evidence in support of a Complaint, before a Hearing Officer who issues an

written decision based upon the evidence presented. This request must be filed within ten (10) days after the date on which the cause giving

rise to the Complaint is known.

[ ] LEVEL II APPEAL – Must be filed within ten (10) calendar days of the Level I Hearing Officer’s Decision.

[ ] LEVEL III APPEAL to the Board of Education – Must be filed within ten (10) calendar days of the Level II Hearing Officer’s

Decision. (Please Note: A Level III Appeal is not available to Classified personnel.)

[ ] UNPROFESSIONAL CONDUCT

[ ] HARASSMENT

[ ] HOSTILE WORK ENVIRONMENT

[ ] BULLYING

[ ] SEXUAL HARASSMENT – Request for an investigation into allegations regarding inappropriate verbal and/or physical contact of a

sexual nature.

Employee’s Name _________________________________________ School or Department ___________________________________

Home Address _____________________________________________ City ______________________ State_________ Zip_________

Email Address ___________________________________________

Home Phone ___________________________Cellular Phone _______________________ Employee ID# _________________________

Date of Hire _______________________ Position/Classification __________________________________________________________

EMPLOYEE’S STATEMENT OF COMPLAINT

1. State the date of the occurrence of the most recent incident or other matter on which the Complaint is based: _________________

________________________________________________________________________________________________________

2. Names(s) and title(s) of charged party or parties: _________________________________________________________________

_________________________________________________________________________________________________________

3. Names(s) of witness(es), if any:_______________________________________________________________________________

_________________________________________________________________________________________________________

Personnel Harassment Complaint Form