Harassment Reporting Form

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Claims of discrimination may also be pursued through the following agencies where appropriate:
U.S. Department of Education
Office for Civil Rights, Region V
500 W. Madison Street – Suite 1475
Chicago, IL 60661
Tel: 312-730-1560
TDD: 312-730-1609

MN Department of Human Rights
190 E 5th Street
St. Paul, MN 55101
800-657-3704
651-296-5663
TDD: 651-296-1283

For complaints of employment discrimination:
Equal Employment Opportunity Commission
330 S. 2nd Avenue
Suite 430
Minneapolis, MN 55401
800-669-4000
612-335-4040
TDD: 612-335-4045

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

What grade level is the person in?

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 information to this if necessary.) *

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

List any witnesses that were present: *

This complaint is filed based on my honest belief that the person/persons identified above has harassed or has been violent to me or to another person or group. 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. (Write out your full name below) *

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