Desktop Schools Popup

Series 405.7.2P - Report of Alleged Harassment, Discrimination, Violence or Hazing

District 196 prohibits all forms of harassment, discrimination--including sex discrimination under Title IX--or violence based on race, color, creed, religion, national origin, sex, marital status, disability, status with regard to public assistance, sexual orientation, membership or activity in a local human rights commission, familial status, genetic information or age. Engaging in this kind of conduct against students, District 196 personnel or other persons is discrimination and a violation of the U.S. Civil Rights Act and the Minnesota Human Rights Act. The school district also prohibits hazing of a student as required by Minnesota Law. 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): 

□  race                            □  national origin           □  marital status

□  religion                        □  sex                            □  creed

□  sexual orientation        □  age                           □  disability

□  color                            □  hazing (of a student)   □  familial status

□  status with regard to public assistance               □  genetic information       

□  membership or activity in a local human rights 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.

Procedure/405.7.2P/11-18-16