FILE:  GAFA-R

HARASSMENT COMPLAINT FORM
Every staff member is expected to report any situation that they believe to be improper harassment.  All complaints must be filed ASAP, but no later than 60 days from the alleged act.

  1. Name of complaint:

 

 

 

 

  1. Status:  Student     Staff     Administrator     Board Trustee     Volunteer     Parent     Other_specify

 

  1. Administrative building/department (if employee):

 

  1. Address:

 

Phone Number:

 

 

  1. Name of individual engaging in alleged harassment:

 

  1. Administrative building/department of individual named in #5 (if employee):

 

  1. Complaint's relationship to individual engaging in alleged harrassment:
      Supervisor     Co-worker     Staff    Advisor     Student    Other_specify

 

  1. Which type of harassment:

 

Please describe the specific act(s) alleged:

 

 

  1. Location(s) of alleged incident:

 

  1. Date(s) and appropriate time(s):

 

  1. Describe the effect of the alleged harassment had on you:

 

 

 

 

  1. Are there others who have witnessed this behavior or others who experienced similar behavior by the individual named above?  If so, please provide their name(s), address(es) and their phone number(s):

 

 

 

 

  1. Did you tell anyone about your experience after the alleged incident?  If so, please provide name(s) and phone number(s).

 

 

 

 

  1. Action taken, if any, by the complainant to attempt to stop the harassment.

 

 

 

 

  1. Have you filed this report with any other agency of an attorney?

Yes     No

If yes, with whom?

 

 

  1. Complainant's suggestion of proposed action to address or resolve the harassment.

 

 

 

 

  1. Additional information and comments (evidence of harassment, I.E., letters, photos, etc., attach if possible):

 

 

 

 

 

 

 

  
Signature of person making the report Date
   
Signature of person receiving the report Date
 

The Benton Harbor Area Schools, Berrien County, Michigan