Report Employee Discrimination and Harassment

General Information

Today's Date *

Name of person completing this form (First, Last) *

First Last

I am (choose one)

Employee
School Partner/Contractor

I am from this school, OR this office (please provide the full name of your school or the office in which you work): *

Email *

Best phone number where we can reach you: *

Name(s) of Alleged Victim(s)

The alleged victim is:

Me
Not me

Alleged Victim is (choose one)

Employee
Student

Alleged Victim's School OR Office (please provide the full name of the school or office):

Name(s) of Accused Person(s)

Accused Person is:

Employee
School Partner/Contractor

Accused Person's School/Office (please write "don't know" if you're not sure):

What is the relationship of the alleged victim to the accused person (i.e. supervisor, colleague, etc.)?

Describe the Incident

Please provide the date(s) and time(s) when the incident occurred. If you do not know, please write "don't know".

Please describe where the incident occurred. If you do not know, please write "don't know".

Did the incident occur during a School District activity or event?

Yes
No

Please provide a detailed description of the incident and try to use specific and objective language (who, what, where, why, and how)

Witness Name(s):

Do you believe the incident was based on a protected category (e.g. race, ethnicity, national origin, color, gender, sex, sexual orientation, gender identity, religion or disability)?

Yes
No

If yes, which protected category or categories do you believe the conduct was based upon?

If no, please describe why you believe you were subjected to this conduct?

To avoid duplication of efforts and to provide the best response, please share with us any other offices or employees that have been notified of this incident.

Please provide any documentation pertaining to your report such as pictures, texts, email messages, etc.

Max. file size: 10 MB.

Office Menu:

Search the site:

Employee Relations

Report Employee Discrimination and Harassment

Employee Discrimination and Harassment Reporting Form

General Information

Describe the Incident