413-Form (electronic)

General Statement of Policy Prohibiting Harassment and Violence

Independent School District No. 477 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, age, marital status, 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, 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.

Information on this form will be routed to the district human rights officers:

Jason Senne, Director of Human Resources
jason.senne@isd477.org

Patrick Devine, Superintendent
pat.devine@isd477.org

Complainant Namerequired

First Name

Last Name

Email Addressrequired

Address, City, State, Zip

Phone Number

Date of Alleged Incident(s)required

Must contain a date in M/D/YYYY format

Name of person you believe harassed or was violent toward you or another person or group.required

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.) required

Where and when did the incident(s) occur?required

List any witnesses that were present.required

This complaint is filed based on my honest belief that ___________ has harassed or has been violent to me or to another person or group. required

Enter alleged violator name.

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.required

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Harassment and Violence Report Form

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