Otsego Elementary School Faculty Handbook - Half Hollow Hills

Has the incident been reported before? Yes No
If yes, when? To whom? _______________________________________________________________
What was the resolution? _______________________________________________________________
Has the complainant been the victim of similar incidents in the past? Yes No
What were the details? _________________________________________________________________
Was the other incident or incidents reported? Yes No
If yes, to whom? ______________________________________________________________________
What was the resolution? _______________________________________________________________
Signature of Complainant _______________________________________ Date ___________________
Signature of Building Administrator_______________________________ Date ___________________
If you need additional space, feel free to attach additional pages to this form.
Actions which may be taken may include, but are not limited to, warning, loss of privileges, exclusion
from school activities and events, denial of access to school property, suspension, expulsion, reporting to
local police authorities, transfer, remediation, termination, or discharge.
NOTE: Any act of retaliation is prohibited. Retaliation includes, but is not limited to, verbal or physical
threats, ridicule, spreading of rumors, bribes, destruction of property, stalking, harassing phone calls,
harassing internet use, any form of intimidation, reprisal or harassment.