Revised: January 11, 1993 512/513 Form
Revised: March 22, 1999
Revised: October 12, 2016
Revised: November 13, 2019
EMPLOYEE HARASSMENT/BULLYING REPORT FORM
General Statement of Policy Prohibiting Employee Harassment:
The Evansville Community School District values and respects the human diversity of members of the school community. In order to maintain a school environment which encourages optimum human growth and development for students, employees and others acting in the District’s behalf, it is the policy of the Board of Education to maintain and ensure a learning and working environment free of any form of employee harassment, intimidation, or bullying.
Complainant Name: __________________________________________________________
Home Address: __________________________________________________________
Work Location: __________________________________________________________
Home Phone: ________________________ Work Phone: ______________________
Cell Phone: ______________________
Date of alleged incident (s): _____________________________________________________
____________________________________________________________________________
Name of alleged harasser(s): ____________________________________________________
Describe the incident(s) as clearly as possible:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
This complaint is filed based on my honest belief that _________________________________
has personally harassed me. I hereby certify that the information I have provided in this complaint is true, correct, and complete to the best of my knowledge and belief.
____________________________________ Date: _____________________________
(Complainant Signature)
Received by: _____________________________ Date: _____________________________
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