EMPLOYEE DISCRIMINATION/HARASSMENT COMPLAINT FORM

Acton School Department encourages you to resolve any problem or issue informally with the individuals involved. However, if you have a concern or experience a problem that affects you   or your co-workers, we ask that you complete this form and return it to the Director of Human Resources. 

To: Director of Human Resources    Date Received: _________________                   

      Acton School Department

      700 Milton Mills Road

      Acton, ME  04001

Employee Information Name of person claiming issue 

______________________________________________________________________ 

Address _______________________________________________________________ 

Telephone # ____________________________________________________________ 

Issue Information Date/time of issue 

______________________________________________________________________ 

Location of issue ______________________________________________________ 

Description of issue (attach narrative) ______________________________________ 

_______________________________________________________________________

 _______________________________________________________________________ 

Witnesses of issue ______________________________________________________ 

How could this problem be resolved?  (Attach additional pages if necessary.) 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

Please complete page 2 of this request form. 

EMPLOYEE DISCRIMINATION/HARASSMENT COMPLAINT FORM (Continued) 

What actions has the school taken to address the problem? 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

Who did you notify?  __________________________ Date notified:  _______ / _______ / _______ 

How did you notify this person? 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

Signature of individual submitting request:  __________________________ Date:  ____ / ____ / ______ 

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Signature of person preparing report: _________________________________________ 

Date: ____________ 

Adopted:          March 14, 2017