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Complainant Information

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(include name, sex and grade)​​
(Please Select One)​​
(Please provide name, sex, grade/position and school.​​


Witness Information

How many witnesses are you providing information for?​​​​

Witness (1) Information:

I am including the following information about this witness:​​
(all that apply)​

Witness (2) Information:

I am including the following information about this witness:​​
(all that apply)​

Witness (3) Information:

I am including the following information about this witness:​​​
(all that apply)​​

Additional Witness/es Information:


Incident Description of Discriminatory and/or Harassing Behaviors

Type of Bias Based on the Person's Actual or Perceived:

(Select all that apply)

(Check all that apply)​
(Select all that apply)​​​


Actions Taken

If you are aware of any actions taken in response to the incident described above, please select all that apply:


Other Alleged Discriminatory and/or Harassing Incidents, if any

Please select One:​​

Include date and description:​​

Please type in your full name.​​​

Please provide an email address where we can send a link to your current form.

Email Address :