INDEPENDENT SCHOOL DISTRICT NO. 2176    

RELIGIOUS, RACIAL, OR SEXUAL HARASSMENT AND VIOLENCE REPORT FORM


General Statement of Policy Prohibiting Religious, Racial, or Sexual Harassment


Independent School District No. 2176 maintains a firm policy prohibiting all forms of discrimination.  Religious, racial, or sexual harassment or violence against students or employees is discrimination.  All persons are to be treated with respect and dignity. Sexual violence, sexual advances or other forms of religious, racial, or sexual harassment by any pupil, teacher, administrator or other school personnel, which create an intimidating, hostile or offensive environment will not be tolerated under any circumstances.


Complainant

Home Address

Work Address

Home Phone                                         Work Phone


Date of Alleged Incident(s)


Circle as appropriate   sexual  \  racial  \  religious.


Name of person you believe harassed or was violent toward you or another person.


If the alleged harassment or violence was toward another person, identify that person.


Describe the incident(s) as clearly as possible, including such things as: what force, if any, was used; any verbal statements (i.e. threats, requests, demands, etc.); what, if any, physical contact was involved; etc.  (Attach additional pages if necessary.)


Where and when did the incident(s) occur?

List any witnesses that were present


This complaint is filed based on my honest belief that                                                 has harassed or has been violent to me or to another person.  I hereby certify that the information I have provided in this complaint is true, correct and complete to the best of my knowledge and belief.


(Complainant Signature) (Date)


Received by

(Date)