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Discrimination and/or Harassment
Reporting Form
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| | 3. | School/Location where the incident occurred: | | |
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| | 4. | Date when the incident occurred: | | |
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| | 5. | Time when the incident occurred: | | |
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| | 6. | The specific location where the incident occurred: (i.e. bathroom near gym, classroom #22) | | |
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| | 8. | The incident was based on: | | |
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| | 9. | Name of the person(s) you believe harassed, discriminated or threatened you or another person: | | |
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| 10. |
If the alleged incident was towards another person, identify that person(s): | | |
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| | 11. | Describe the incident 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. | | |
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| 12. | List any witnesses who were present: | | |
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| | 13. | What would you like to see happen? | | |
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| | 14. | Acknowledgment of Correct Information
I declare that the foregoing information is true and correct. I understand that neither I, nor anyone involved in the incident, are to retaliate against the other party. I also have the right not to be retaliated against by the other party involved in this incident. If I feel threatened in any way, or have concerns, I will contact the person in charge of this complaint. I hereby certify the information I have provided in this complaint is true, correct, and complete to the best of my knowledge. | | |
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| | 15. | Signature
Entering your name here indicates a digital signature: | | |
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