HARASSMENT, BULLYING AND DISCRIMINATION REPORTING FORM (Staff Form)

person reporting alleged incident (if this is an anonymous report, leave contact information blank)

Last Name / First Name / Telephone Number
Address / School/Worksite / Position
Type of Incident
____ Harassment ____ Sexual Harassment
____ Bullying
____ Discrimination / Name & Position of Alleged Offender: / Date & Location of Incident
Name of Victim: / Name of Witnesses:

Description of incident (ATTACH ADDITIONAL PAGES IF NECESSARY)

LIST AND/OR ATTACH eVIDENCE OF HARASSMENT, BULLYING Or DISCRIMINATION (I.E. LETTERS, EMAILS, PHOTOS):

ATTACH ADDITIONAL PAGES, IF NECESSARY, TO DESCRIBE ACTIONS YOU HAVE TAKEN, IF ANY, TO ADDRESS THE ISSUE.
I AGREE THAT ALL THE INFORMATION ON THIS FORM IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE

Signature: ______Date:______

(if this is an anonymous report, you do not have to sign.)

RECEIVED BY: ______DATE: ______

This form should be submitted to your immediate supervisor. If your immediate supervisor is the alleged offender, this form may be submitted to the Chief Human Resources Officer or the Executive Director for Human Resources. For complete information, see Board Policy GAMA-P.

In compliance with federal laws, Guilford County Schools administers all educational programs, employment activities and admissions without discrimination because of race, religion, national or ethnic origin, color, age, military service, disability or gender, except where exemption is appropriate and allowed by law. Refer to the Board of Education's Harassment, Bullying and Discrimination Free Environment Policy for a complete statement. Inquiries or complaints should be directed to the Guilford County Schools Compliance Officer, 120 Franklin Boulevard, Greensboro, NC 27401; 336.370.2323. All Guilford County Schools facilities, both educational and athletic, are tobacco-free learning environments.

Witness Disclosure Form

person WITNESSING AN alleged incident

Witness Last Name / Witness First Name / School/Work site / Telephone Number
Address / School/Worksite / Position
Type of Incident
____ Harassment ____ Sexual Harassment
____ Bullying
____ Discrimination / Name & Position of Alleged Offender / Date & Location of Incident
Name of Victim: / Name of Witnesses:

Description of incident witnessed (ATTACH ADDITIONAL PAGES IF NECESSARY)

LIST AND/OR ATTACH eVIDENCE OF HARASSMENT, BULLYING Or DISCRIMINATION (I.E. LETTERS, EMAILS, PHOTOS):

ATTACH ADDITIONAL PAGES, IF NECESSARY, TO DESCRIBE ACTIONS YOU HAVE TAKEN, IF ANY, TO ADDRESS THE ISSUE.
I AGREE THAT ALL THE INFORMATION ON THIS FORM IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE

Signature: ______Date:______

RECEIVED BY: ______DATE: ______

This form should be submitted to your immediate supervisor. If your immediate supervisor is the alleged offender, this form may be submitted to the Chief Human Resources Officer or the Executive Director for Human Resources. For complete information, see Board Policy GAMA-P. In compliance with federal laws, Guilford County Schools administers all educational programs, employment activities and admissions without discrimination because of race, religion, national or ethnic origin, color, age, military service, disability or gender, except where exemption is appropriate and allowed by law. Refer to the Board of Education's Harassment, Bullying and Discrimination Free Environment Policy for a complete statement. Inquiries or complaints should be directed to the Guilford County Schools Compliance Officer, 120 Franklin Boulevard, Greensboro, NC 27401; 336.370.2323. All Guilford County Schools facilities, both educational and athletic, are tobacco-free learning environments.