548.  ATTACHMENT
REPORT FORM FOR COMPLAINTS OF UNLAWFUL HARASSMENT
Complainant: __________________________________________________________________
Home Address: ________________________________________________________________
Home Phone: __________________________________________________________________
School Building: _______________________________________________________________
Date of Alleged Incident(s): ______________________________________________________
Alleged harassment was based on: (circle those that apply)
Race
Color
National Origin
Gender
Age
Disability
Religion
Sexual Orientation
Name of person you believe violated the district's unlawful harassment policy:
______________________________________________________________________________
If the alleged harassment was directed against another person, identify the other person: 
______________________________________________________________________________
Describe the incident as clearly as possible, including what force, if any, was used; verbal
statements (i.e. threats, requests, demands, etc.); what, if any, physical contact was involved.
Attach additional pages if necessary: ________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
When and where incident occurred: ________________________________________________
List any witnesses who were present: _______________________________________________
______________________________________________________________________________
This complaint is based on my honest belief that ________________________ has harassed me
or another person. I certify that the information I have provided in this complaint is true, correct
and complete to the best of my knowledge.
_____________________________
_______________________
Complainant's Signature
Date
_____________________________
_______________________
Received By
Date