Personnel Harassment Complaint Form (Page 2 of 2) in pdf

4. What statute, policy, rule, regulation, or written agreement has been violated, misapplied, or misinterpreted? _________________

_________________________________________________________________________________________________________

5. Briefly describe the specific facts or events on which the Complaint is based. Explain how such statute, policy, rule, regulation, or

written agreement was violated, misapplied, or misinterpreted, and how it affects the employment relationship or the Complainant?

Please include names, dates, places, times and other specifics on attached page(s) if needed._______________________________

_________________________________________________________________________________________________________

6. How are you affected by the alleged violation of your employment?__________________________________________________

_________________________________________________________________________________________________________

7. What relief are you seeking? _________________________________________________________________________________

_________________________________________________________________________________________________________

I hereby present the following Complaint to the Office of Internal Affairs. I understand that this Complaint will be

reviewed and investigated in accordance with the Superintendent’s procedures and the adopted Board of Education’s

Complaint Resolution Policies.

______________________________________________________________

_____________________

Employee’s Signature

Date

Revised and Issued 07/13/2011

Personnel Harassment Complaint Form Page 2