INDEPENDENT SCHOOL DISTRICT NO.		
HARASSMENT AND VIOLENCE REPORT FORM

General Statement of Policy Prohibiting Harassment and Violence

Independent School District No.       maintains a firm policy prohibiting all forms of discrimination.  Harassment or violence against students or employees or groups of students or employees on the basis of race, color, creed, religion, national origin, sex, age, marital status, familial status, status with regard to public assistance, sexual orientation, including gender identity and expression, or disability is strictly prohibited.  All persons are to be treated with respect and dignity. Harassment or violence on the basis of race, color, creed, religion, national origin, sex, age, marital status, familial status, status with regard to public assistance, sexual orientation, including gender identity and expression, or disability by any pupil, teacher, administrator, or other school personnel, which create an intimidating, hostile, or offensive environment will not be tolerated under any circumstances.

Complainant												
Home Address												
Work Address												
Home Phone                                         Work Phone				

Date of Alleged Incident(s)										

Basis of Alleged Harassment/Violence - circle as appropriate:  race \ color \ creed \ religion \ national origin \ sex \ age \ marital status \ familial status \ status with regard to public assistance \ sexual orientation, including gender identity and expression \ disability

Name of person you believe harassed or was violent toward you or another person or group.

If the alleged harassment or violence was toward another person or group, identify that person or group.													

Describe the incident(s) 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; etc.  (Attach additional pages if necessary.)							

													

Where and when did the incident(s) occur?								

List any witnesses that were present									

This complaint is filed based on my honest belief that                                                 has harassed or has been violent to me or to another person or group.  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.

													
(Complainant Signature)				(Date)

Received by												
							(Date)