Complainant Name:
School Name or Position (if applicable):
Student Parent Employee Non-employee Job Applicant Other
Address: City: State: Zip:
Phone:
Email Address:
Date(s) of alleged incident(s)/conduct:
Location(s) where alleged incident(s)/conduct took place:
Name of person(s) who engaged in the conduct:
Names of any witnesses:
Do you have any evidence (e.g. emails, photos, text messages, etc.)? Yes No
Describe the incident(s)/conduct as clearly as possible:
This complaint is filed based on my honest belief that has engaged in conduct involving one or more of the following (mark all that apply):
Harassment based on my sex (including gender identity, sexual orientation, and pregnancy, childbirth or any related medical conditions.
Retaliation based on:
Suggested resolution/desired outcome:
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Complainant Signature:
Date: