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503.4.2P - Report of Alleged Harassment, Discrimination, Violence or Hazing

503.4.2P - Report of Alleged Harassment, Discrimination, Violence or Hazing

Adopted:  August 2006
Revised:  July 2023

Download 503.4.2P - Report of Alleged Harassment, Discrimination, Violence or Hazing

District 196 prohibits all forms of illegal harassment, discrimination--including sex discrimination under Title IX--or violence based on sex, race, religion, color, creed, national origin, marital status, familial status, disability, status with regard to public assistance, sexual orientation, gender identity, membership or activity in a local human rights commission, age or genetic information.* Engaging in this kind of conduct against students, District 196 personnel or other persons is discrimination and a violation of U.S. law and the Minnesota Human Rights Act. The school district also prohibits hazing of a student. All persons are to be treated with respect and dignity. Harassment, discrimination, violence or hazing by any person will not be tolerated under any circumstances.

Complainant name (please print)                                                                                          

Home address                                                                                                                      

Work address                                                                                                                       

Home phone (_____)                                          Work phone (_____)                                                  

Date(s) of alleged incident(s):                                                                                                          

 

Alleged incident(s) was/were based on (check as appropriate): 

 

□  sex                          □  national origin                    □  gender identity

□  race                         □  marital status                     □  age                         

□  religion                   □  familial status                    □  genetic information

□  color                       □  disability                             □  status with regard to public assistance      

□  creed                       □  sexual orientation              □  membership or activity in a local human

    commission

Name of person you believe harassed, discriminated, or was violent toward you or another person, or hazed you or another person:                                                                                                                                                                                                                                  

 

If the alleged harassment, discrimination, violence or hazing was toward another person, identify that person:                                                                                                        

 

List any witnesses who were present:                                                                                                                                                                                                                                          

 

Where and when did the incident(s) occur?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               

                                                                                                                                           

Describe the incident(s) as clearly as possible, including such things as what force, if any, was used; any verbal statements (i.e., threats, requests, demands, etc.); what, if any, physical contact was involved and what you did to avoid the situation, etc.  (Attach additional pages if necessary.)

                                                                                                                                                                                                                                                                                                                                                                                                                                   

 

This complaint is filed based on my honest belief that                                                           

has harassed, discriminated, or has been violent to me or to another person, or has been involved in hazing me or another person.  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. 

 

Signature of Complainant X                                                                    Date                                                                                                      

 

Received by                                                                                              Date                                                                                                                                                                                                                  

 

·     If the report relates to student conduct, this report must be submitted to the principal, counselor, psychologist, teacher or the appropriate Human Rights Officer which would be:

o   For grades K-5:       Director of Elementary Education or

o   For grades 6-12:      Director of Secondary Education.

·     If the report relates to adult conduct, this report must be submitted to the principal, counselor, psychologist, teacher or the appropriate Human Rights Officer which would be the Director of Human Resources.

·     If the report relates to the disability of a student, including their rights under Section 504, the appropriate Human Rights Officer is the Director of Special Education.

*   Some categories listed are only protected from certain limited forms of discrimination or harassment.