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Western Mennonite School Formal Harassment Complaint Form (blue form) Brief Description of Problem: (What happened: Described actions or comments which were unwanted and unwelcomed by you. Include others who were involved.) ___________________________________________________________________ ___________________________________________________________________ Factual Information: (Dates, witnesses, location, etc.) Continue on back if necessary. ___________________________________________________________________ ___________________________________________________________________ Your Actions: (What did you do to let the person(s) know that you found the behavior offensive? ___________________________________________________________________ ___________________________________________________________________ Desired Resolution: (What do you want?) ___________________________________________________________________ ___________________________________________________________________ Choice of Processes: (Complaints filed using this form will be handled using the formal complaint process. If you prefer that this matter be handled in the informal process, please use that form. ________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Please use additional paper to elaborate on any answer given above. Signature: ________________________________ Date: ________________ It is the policy of this organization to treat this matter discreetly. However, complete confidentiality cannot be guaranteed due to the nature of an investigation. Thank you for your effort to help keep harassment out of our school. Received by: ______________________________ Date: _________________ Resolution: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________


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