Series 405.7.2P - Report of Alleged Harassment, Discrimination, Violence or Hazing
Adopted: November 1987
Revised: November 2016
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) _______________________________________________
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.