COMPLAINT FORM

(Discrimination, Anti-Bullying, and Anti-Harassment)

Date of complaint:

Name of Complainant:

Are you filling out this form for yourself or someone else (please identify the individual if you are submitting on behalf of someone else):

Who or what entity do you believe discriminated against, harassed, or bullied you (or someone else)?

Date and place of alleged incident(s):

Names of any witnesses (if any):

Nature of discrimination, harassment, or bullying alleged (check all that apply):

• Age
• Disability
• Familial Status
• Gender Identity
• Marital Status
• National Origin/Ethnic Background/Ancestry
• Physical Attribute
• Physical/Mental Ability
• Political Belief
• Political Party Preference
• Race/Color
• Sex
• Sexual Orientation
• Socio-economic Background
• Other – Please Specify:

In the space below, please describe what happened and why you believe that you or someone else has been discriminated against, harassed, or bullied.  Please be as specific as possible and attach additional pages if necessary.

I agree that all of the information on this form is accurate and true to the best of my knowledge.

Signature:
Date:

Adopted: Unknown
Revised/Reviewed: 10.7.2019

Reviewed 01.17.2022

WITNESS DISCLOSURE FORM

Name of Witness:

Date of Interview:

Date of initial complaint:

Name of Complainant (include whether the Complainant is a student or employee):

Date and place of alleged incident(s):

Nature of discrimination, harassment, or bullying alleged (check all that apply):

• Age
• Disability
• Familial Status
• Gender Identity
• Marital Status
• National Origin/Ethnic Background/Ancestry
• Physical Attribute
• Physical/Mental Ability
• Political Belief
• Political Party Preference
• Race/Color
• Religion/Creed
• Sex
• Sexual Orientation
• Socio-economic Background
• Other – Please Specify:

Description of incident witnessed:

Additional information:

I agree that all of the information on this form is accurate and true to the best of my knowledge.

Signature:
Date:

Adopted: Unknown
Revised/Reviewed: 10.7.2019

Reviewed 01.17.2022

DISPOSITION OF COMPLAINT FORM

Date:

Date of initial complaint:

Name of Complainant (include whether the Complainant is a student or employee):

Date and place of alleged incident(s):

Name of Respondent (include whether the Respondent is a student or employee):

Nature of discrimination, harassment, or bullying alleged (check all that apply):

• Age
• Disability
• Familial Status
• Gender Identity
• Marital Status
• National Origin/Ethnic Background/Ancestry
• Physical Attribute
• Physical/Metal Ability
• Political Belief
• Political Party Preference
• Race/Color
• Religion/Creed
• Sex
• Sexual Orientation
• Socio-economic Background
• Other – Please Specify:

Summary of Investigation:

I agree that all of the information on this form is accurate and true to the best of my knowledge.

Signature:
Date:

Adopted: Unknown
Revised/Reviewed: 10.7.2019

Reviewed 01.17.2022

ANTI-BULLYING/ANTI-HARASSMENT INVESTIGATION PROCEDURES

The Harlan Community School District is committed to providing all students and staff with a safe and civil school environment in which all members of the school community are treated with dignity and respect. Bullying and/or harassment of or by students, staff, and volunteers is against federal, state, and local policy and is not tolerated by the board. Bullying and/or harassing behavior can seriously disrupt the ability of school employees to maintain a safe and civil environment, and the ability of students to learn and succeed. Therefore, it is the policy of the state and the school district that school employees, volunteers, and students shall not engage in bullying or harassing behavior in school, on school property, or at any school function or school-sponsored activity.

Definitions

For the purposes of this policy, the defined words shall have the following meaning: 

• “Electronic” means any communication involving the transmission of information by wire, radio, optic cable, electromagnetic, or other similar means. “Electronic” includes but is not limited to communication via electronic mail, internet-based communications, pager service, cell phones, and electronic text messaging.
• “Harassment” and “bullying” shall mean any electronic, written, verbal, or physical act or conduct toward a student based on the individual’s actual or perceived age, color, creed, national origin, race, religion, marital status, sex, sexual orientation, gender identity, physical attributes, physical or mental ability or disability, ancestry, political party preference, political belief, socioeconomic status, or familial status, and which creates an objectively hostile school environment that meets one or more of the following conditions:

1. Places the student in reasonable fear of harm to the student’s person or property.
2. Has a substantial detrimental effect on the student’s physical or mental health.
3. Has the effect of substantially interfering with a student’s academic performance.
4. Has the effect of substantially interfering with the student’s ability to participate in or benefit from the services, activities, or privileges provided by a school.

• “Trait or characteristic of the student” includes but is not limited to age, color, creed, national origin, race, religion, marital status, sex, sexual orientation, gender identity, physical attributes, physical or mental ability or disability, ancestry, political party preference, political belief, socioeconomic status, or familial status.
• “Volunteer” means an individual who has regular, significant contact with students.

Filing a Complaint

A Complainant who wishes to avail himself/herself of this procedure may do so by filing a complaint with the superintendent or superintendent’s designee. In the event it is claimed that the superintendent or superintendent’s designee committed the alleged discrimination or has some other conflict of interest, the complaint should be filed with the elementary principal, serving as an alternate.  Complaints shall be filed within 30 days of the event giving rise to the complaint or from the date the Complainant could reasonably become aware of such occurrence. The Complainant will state the nature of the complaint and the remedy requested. The Complainant shall receive assistance as needed.

School employees, volunteers, and students shall not engage in reprisal, retaliation, or false accusation against a victim, witness, or an individual who has reliable information about an act of bullying or harassment. 

Investigation

The school district will promptly and reasonably investigate allegations of bullying or harassment. The superintendent or superintendent’s designee, or the alternate (hereinafter “Investigator”) will be responsible for handling all complaints alleging bullying or harassment.

If the Complainant is under 18 years of age, the Investigator shall notify his or her parent(s)/guardian(s) that they may attend investigatory meetings in which the Complainant is involved. The complaint and identity of the Complainant, Respondent, or witnesses will only be disclosed as reasonably necessary in connection with the investigation or as required by law or policy. The investigation may include, but is not limited to the following:

• A request for the Complainant to provide a written statement regarding the nature of the complaint;
• A request for the individual named in the complaint (hereinafter “Respondent”) to provide a written statement;
• A request for witnesses identified during the course of the investigation to provide a written statement; and
• Review and collection of documentation or information deemed relevant to the investigation.

The Investigator shall consider the totality of circumstances presented in determining whether conduct objectively constitutes bullying or harassment. Upon completion of the investigation, the Investigator shall issue a report with respect to the findings.

Decision

If, after an investigation, a student is found to be in violation of the policy, the student shall be disciplined by appropriate measures, which may include suspension and expulsion. If after an investigation a school employee is found to be in violation of this policy, the employee shall be disciplined by appropriate measures, which may include termination. If after an investigation a school volunteer is found to be in violation of this policy, the volunteer shall be subject to appropriate measures, which may include exclusion from school grounds.

A school employee, volunteer, or student, or a student’s parent or guardian who promptly, reasonably, and in good faith reports an incident of bullying or harassment, in compliance with the procedures in the policy adopted pursuant to this section, to the appropriate school official designated by the school district, shall be immune from civil or criminal liability relating to such report and to participation in any administrative or judicial proceeding resulting from or relating to the report.

Individuals who knowingly file false bullying and/or harassment complaints and any person who gives false statements in an investigation may be subject to discipline by appropriate measures, as shall any person who is found to have retaliated against another in violation of this policy. Any student found to have retaliated in violation of this policy shall be subject to measures up to, and including, suspension and expulsion. 

Any school employee found to have retaliated in violation of this policy shall be subject to measures up to, and including, termination of employment. Any school volunteer found to have retaliated in violation of this policy shall be subject to measures up to, and including, exclusion from school grounds. 
 

Adopted: Unknown
Revised/Reviewed: 10.21.2019

Reviewed 01.17.2022