|
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: |