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ACB-R3 Student/Parent/Community
Member Reporting Form
Report form
for reports or complaints of sexual harassment, and harassment because of
race, national origin, and disability Complainant Home Address Work Address
(if applicable) Home Phone Work Phone Date of
alleged incident(s) Did the
Incident involve: o Sexual harassment o Racial harassment o Harassment because of a disability o Physical or verbal violence Name of person
you believe harassed you or another person: If the alleged
harassment was toward another person, identify that person: Describe the
incident: (include such things as what force, if any, was used, any verbal
statements, any physical contact, attach additional pages in needed) When and where
did the incident occur? List any
witnesses who were present: The complaint
is based upon my honest belief that _________________________ harassed me or
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. Complainant’s
signature Date Received by Date Adoption Date: Reviewed/Approved: |