Religious, Racial or Sexual Harassment and Violence Report Form Independent School District #84 maintains a firm policy prohibiting all forms of discrimination. Religious, racial or sexual harassment or violence against students or employees is discrimination. All person are to be treated with respect and dignity. Sexual violence, sexual advance 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.


Your Name:
 
First Name
M.
Last Name
Date:
 
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Click on the appropriate violation:
 
Name:
 
First Name
M.
Last Name

Name of person you believe harassed or was violent toward you or another person.
Name:
 
First Name
M.
Last Name

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

Describe as clearly as possible, including such things as: what force, if any, was used; verbal statements (ie threats, requests, demands, etc); what, if any, physical contact was involved; etc.
Where:
 

Please describe the location of the alleged incident.
When:
 
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Indicate the date of the alleged incident.
Witnesses:
 

List any witnesses who were present.
Religious, Racial or Sexual Harassment and Violence Report Form:
 

This complaint is filed based on my honest belief that the above person 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.