Spearfish School District 40-2
5000 Students

5130/4101FM

 HARASSMENT GRIEVANCE FORM
(To be used by designated contact person)

Name of Complainant_________________________________________________________

Address of Complainant_______________________________________________________

Date of Complaint____________________________________________________________

Date and Place of Incident(s)____________________________________________________

Type of Harassment __________________________________________________________
 
Description of the Incident(s)___________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Witnesses___________________________________________________________________

What action, if any, has been taken ______________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Other Comments or Information_________________________________________________

___________________________________________________________________________

___________________________________________________________________________

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

Signature (optional)_______________________________________Date_________________