DKB – Policy Exhibit 1

Report of Sexual Harassment

This form shall be maintained as confidential by the District within the limitations outlined in policy.

Name: __________________________________

Home Telephone Number: __________________

Street Address: ___________________________

Employment Position:  _____________________

School: _________________________________

Street Address: ___________________________

The particulars are (if additional space is needed, attach extra sheets): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Persons Involved: _____________________________________________________________________________________________________________________________

Description of dates, places and nature of sexual harassment: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Witnesses (if any): ______________________________________________________________________________________________________________________________

                                                                        __________________________________________________

                                                                        Signature of Complaining Person