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Ool or Work) Name of individual filing complaint: _____________________________________________________ [ ] Student [ ] Employee [ ] Parent [ ] Other Please Specify ______________ The complaint alleges harassment on the basis of: _________________________________________ Statement of Complaint. Please describe as best you can exactly what happened to you that leads you to believe that you have been harassed. Include dates, if you can, and the names of everyone who was involved in the harassm.

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