Grievance Report Form

PURPOSE

The Waldorf School of Saratoga Springs protects the dignity of all students to provide an environment that is free from actual or perceived discrimination based on race, color, weight, national origin, ethnic group, religion, religious practice, disability, sexual orientation, gender, or sex. The purpose of this Grievance Form is to gather the essential facts related to a complaint of bullying, cyberbullying, sexual harassment or discrimination, including sexual assault or other inappropriate sexual contact, or any other form of discrimination so that a prompt and equitable resolution can be achieved.

INSTRUCTIONS

Individuals requesting the School investigate and resolve their allegation of discrimination, bullying, cyber-bullying, or sexual harassment are required to complete this form and submit it to the School Administrator as soon as possible after the occurrence of the alleged harassment or discrimination:

School Administrator
The Waldorf School of Saratoga Springs
62 York Avenue
Saratoga Springs NY, 12866
(518) 587-0549

Grievance Form

Name of Complainent

First Name

Last Name

Name

First Name

Last Name

Address

Phone

(###)

###

####

Student Name and Grade

Where and when did the incident occur? Please be specific. Include location, month, date, year, and time.

How did you find out about this incident? Did you witness the incident directly or were you told about the incident? If you were told, by whom?

Name the offender (include first and last name):

First Name

Last Name

Name the victim (include first and last name):

First Name

Last Name

Please list any witnesses (include first and last names):

Describe the incident in as much detail as possible:

Has this bullying/ harassment happened to the victim before?

If this has happened before have you reported it to anyone?

If you have reported before to whom did you report? (Please give first and last names.)