AC-TCA-F1 | Report of Discrimination or Harassment
This form requires Javascript to be enabled for submission and authorization.
*
Required
The Classical Academy
Report of Discrimination or Harassment
Reporter's Information:
*
required
First Name
Last Name
Email Address:
*
required
Phone Number
*
required
Status of Reporter:
*
required
Please select up to 1 choice
Student
Staff
Teacher
Other (explain below)
Please select up to 1 choice
Grade (for students):
*
required
Department (for staff):
*
required
Status (If Other):
*
required
Campus:
*
required
Date of Report:
*
required
Must contain a date in M/D/YYYY format
If the reporter is not the alleged target, identify the alleged target(s):
Basis of Discrimination or Harassment
*
required
Please select up to 11 choices
Race
Color
Sex
Sexual Orientation
Religion
National Origin
Age (over 40)
Marital Status
Pregnancy
Disability
Retaliation
Please select up to 11 choices
Offender's Information
Name(s) of Alleged Perpetrators of Discrimination/Harassment:
*
required
Status of Alleged Perpetrator(s):
*
required
Please select up to 1 choice
Student
Staff
Teacher
Other (explain below)
Please select up to 1 choice
Grade (for students)
*
required
Department (for staff):
*
required
Status (If Other):
*
required
Location:
*
required
Relationship of Alleged Perpetrator(s) to Reporter:
*
required
Please select up to 1 choice
Supervisor
Co-Worker
Teacher
Student
Classmate
Other (explain below)
Please select up to 1 choice
Relationship (if other):
*
required
Description of Events:
*
required
0 / 5000
Describe specific acts alleged with dates, times, and locations, if possible.
Has anyone witnessed the alleged behavior?
*
required
Please select up to 1 choice
Yes
No
Please select up to 1 choice
Please list the names and contact information, if known.
*
required
Did you take any action to stop the discrimination/harassment?
*
required
Please select up to 1 choice
Yes
No
Please select up to 1 choice
Please summarize the action taken:
*
required
How would you like to see the situation resolved?
*
required
Additional Information or comments:
*
required
Type full name to digitally sign this form:
*
required
Date:
*
required
Please send all correspondence to me at the following:
*
required
Email/Phone
Preferred numbers for phone contact:
*
required
Home/Cell
I was assisted in completing this form by:
TCA Policy AC-TCA-F1 replaces ASD20 Policy AC-E-2 | Report of Discrimination/Harassment | President | Last Reviewed: 6/01/2024
Submit