102E4 - Complaint Form

COMPLAINT FORM

(Discrimination, Anti-Bullying, and Anti-Harassment)

Date of complaint:	_____________________________________________________
Name of Complainant:	_____________________________________________________
Are you filling out this form for yourself or someone else (please identify the individual if you are submitting on behalf of someone else):	_____________________________________________________ _____________________________________________________
Who or what entity do you believe discriminated against, harassed, or bullied you (or someone else)?	_____________________________________________________
Date and place of alleged incident(s):	_____________________________________________________ _____________________________________________________ _____________________________________________________
Names of any witnesses (if any):	_____________________________________________________

Nature of discrimination, harassment, or bullying alleged (check all that apply):

Age	Physical Attribute	Sex
Disability	Physical/Mental Ability	Sexual Orientation
Familial Status	Political Belief	Socio-economic Background
Gender Identity	Political Party Preference	Other – Please Specify:
Marital Status	Race/Color
National Origin/Ethnic Background/Ancestry	Religion/Creed

In the space below, please describe what happened and why you believe that you or someone else has been discriminated against, harassed, or bullied. Please be as specific as possible and attach additional pages if necessary.

___________________________________________________________________________________________

I agree that all of the information on this form is accurate and true to the best of my knowledge.

Signature: _____________________________________ Date: __________________________

Approved: 12/17/2018 Reviewed: 11/19/2018 Revised: 10/17/2016

Jen@iowaschool… Mon, 04/04/2022 - 21:05