502.10E1 Anti-Bullying and 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: _____ /_____ /_____