Exhibit CF-E1 - Harassment Documentation and Complaint Form

Name of alleged victim(s) of harassment:

__ Student __ PSSD Staff __ Other:

School:

Home address:

Home telephone:

Name of alleged harasser(s):

__ Student __ PSSD Staff __ Other:

Name of person completing this form (if different from alleged victim):

__ Student __ PSSD Staff __ Other:

Date incident occurred: _________________________________ Time incident occurred: ___________________________________

Place incident occurred:

Detailed description of incident; Who, Where, What, When, How: (Additional space available on reverse.)

Names of persons witnessing the incident:

Names of person to whom this incident was reported:

Agreed upon method of dealing with this incident:

__ Informal complaint __ Formal complaint

(To be discussed with the person assigned to action this complaint.)

Signature of complainant

Date

Received by (name and title) signature

of recipient

Date received

Referred to (person and title)

Date received

Received by (name and title) signature

of recipient

Date received

Signature of recipient

Date received

Detailed description of incident; Who, Where, What, When, How: (Continued from first page)

Signature of complainant

Date

Received by (name and title) signature

of recipient

Date received

Referred to (person and title)

Date received

Received by (name and title) signature

of recipient

Date received

Signature of recipient

Date received