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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 .)

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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