Killingly Public Schools - BoE Policy 5145.5 Form
COMPLAINT REGARDING SEX DISCRIMINATION AND SEXUAL HARASSMENT
Name of the complainant:
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First Name
Last Name
Date of the complaint:
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/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of the alleged discrimination/harassment:
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Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name or names of the discriminator(s) or harasser(s):
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Location where such discrimination/harassment occurred:
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Name(s) of any witness(es) to the discrimination/harassment:
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Provide a detailed statement of the circumstances constituting the alleged discrimination or harassment:
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Remedy requested:
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Acknowledgement:
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I acknowledge that the information contained within this complaint is presented truthfully, and in good faith, to the best of my ability.
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