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502.1 Anti-Bullying / Anti-Harassment Complaint Form

ANTI-BULLYING / ANTI-HARASSMENT COMPLAINT FORM

Name of complainant:

 

Position of complainant:

 

Date of complaint:

 

Name of alleged harasser or bully:

 

Date and place of incident or incidents:

 

 

 

 

 

 

 

Description of incident or incidents:

 

 

 

 

 

 

 

 

 

 

 

Name of witnesses (if any):

 

 

 

 

 

 

 

 

 

Evidence of harassment or bullying, i.e., letters, photos, etc. (attach evidence if possible):

 

 

 

 

 

 

 

Any other information:

 

 

 

 

 

 

 

 

 

 

 

 

 

I agree that all of the information on this form is accurate and true to the best of my knowledge.

 

 

 

 

Signature:

 

 

Date:

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