DKB-1

Report of Sexual Harassment

This form shall be maintained as confidential by the District within the limitations outlined in policy.

Name: __________________________________

Home Telephone Number: __________________

Street Address: ___________________________

Employment Position:  _____________________

School: _________________________________

Street Address: ___________________________

The particulars are (if additional space is needed, attach extra sheets): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Persons Involved: ________________________________________________________________________________________________________________________________

Description of dates, places and nature of sexual harassment: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Witnesses (if any): ________________________________________________________________________________________________________________________________

                                                                        ___________________________

                                                                        Signature of Complaining Person