413 HARASSMENT AND VIOLENCE REPORT FORM
General Statement of Policy Prohibiting Harassment and Violence
The Journey School (TJS) maintains a firm policy prohibiting all forms of discrimination. Harassment or violence against students or employees or groups of students or employees on the basis of race, color, creed, religion, national origin, sex, gender, age, marital status, and familial status, status with regard to public assistance, sexual orientation, or disability is strictly prohibited. All persons are to be treated with respect and dignity. Harassment or violence on the basis of race, color, creed, religion, national origin, sex, gender, age, marital status, familial status, status with regard to public assistance, sexual orientation, or disability by any pupil, teacher, administrator, or other school personnel, which create an intimidating, hostile, or offensive environment will not be tolerated under any circumstances.
Complainant: _____________________
Phone #: _____________________
Date of Alleged Incident(s): _________________________
Basis of Alleged Harassment/Violence – circle as appropriate:
race \ color \ creed \ religion \ national origin \ sex \ gender \ age \ marital status \ familial status \ status with regard to public assistance \ sexual orientation \ disability –
Other: _________________________
Name of person you believe harassed or was violent toward you or another person or group:
_________________________
_________________________
_________________________
If the alleged harassment or violence was toward another person or group, identify that person or group:
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;
etc. (Attach additional pages if necessary.):
Where did the incident(s) occur? _________________________
Time: _________________________
List any witnesses that were present:
_________________________
_________________________
_________________________
This complaint is filed based on my honest belief that has harassed or has been violent to me or to another person or group. 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.
Complainant Signature: __________________________________
Date: _________________________
Received by: _________________________
Date: _________________________
Time: _________________________