0521
Form
Complainant:
Home Address:
Home Phone:
School Building:
Date of Alleged Incident(s):
REPORT FORM FOR COMPLAINTS OF DISCRIMINATION
Alleged harassment was based on: (Check all that apply.)
Race Color National Origin Gender Identity or Expression
Gender Disability Religion
Ancestry Age Sexual Orientation
Name of person you believe violated the District’s nondiscrimination policy:
______________________________________________________________________________
If the alleged discrimination was directed against another person, identify the other person:
______________________________________________________________________________
Describe the incident as clearly as possible, including any verbal statements (i.e., threats,
derogatory remarks, demands, etc.) and any actions or activities. Attach additional pages if
necessary:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________
When and where incident occurred:
List any witnesses who were present:
This complaint is based on my honest belief that _________________________________ has discriminated
against me or another person. I certify that the information provided in this complaint is true, correct and
complete to the best of my knowledge.
__________________________
Complainant’s Signature
__________________________
Received By
_______________________
Date
_______________________
Date
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