503.5E1 - Anti-Bullying/Harassment Complaint Form

Name of Complainant:
_________________________________________________________________________________________________________

Position of complainant:  _____________________________________________________________________________________

Date of complaint:  __________________________________________________________________________________________

Name of alleged harasser or bully:  _____________________________________________________________________________

Date and place of incident or incidents:  _________________________________________________________________________
_________________________________________________________________________________________________________

Description of incident or incidents:  ____________________________________________________________________________
_________________________________________________________________________________________________________

Name of witnesses (if any):  __________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

Evidence of harassment or bullying, i.e. letters, photos, etc (attach evidence if possible):
_________________________________________________________________________________________________________

Any other information:  ______________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

I agree all of the information on this form is accurate and true to the best of my knowledge.

 

Signature:  ______________________________________________________________

Date:  __________________________________________________________________