* Required

Discrimination and/or Harassment Report Form

Regional School District #18 prohibits all forms of discrimination and/or harassment as defined by district policy. Any person who feels they may have been discriminated against and/or harassed should contact their building administrator or an Equity Officer (LOLHS - Director of Counseling; LOLMS - School Psychologist; Center School/Preschool - School Psychologist; Lyme Consolidated School - School Psychologist; Mile Creek School - School Psychologist; District - Director of Special Services: 860-434-0487.

Name of Complainantrequired

Schoolrequired

Date of Alleged Incident(s)required (mm/dd/yyyy)

Name of person you believe discriminated against and/or harassed yourequired

List any witnesses

Where did the incident(s) occur?required

Describe the incident(s) including information regarding the nature of the incident, verbal statements, force, physical contact, responses or attempt to resolve the issue informally.required

How would you like to see the issue resolved?required

Today's Daterequired (mm/dd/yyyy)