TITLE IX GRIEVANCE FORM
ENFIELD PUBLIC SCHOOLS
ENFIELD , CONNECTICUT Administrative Regulation 5410
Any student , parent / guardian , employee or employment applicant who feels that he / she has been discriminated against on the basis of race , color , age , national origin , sex or handicap may discuss and / or file a grievance with the Title IX Coordinator . Reporting should take place within twenty ( 20 ) calendar days of the alleged discrimination . Title IX Coordinator is :
Christopher J . Drezek Enfield Public Schools Deputy Superintendent 27 Shaker Road Enfield , CT 06082 253-6532
NAME OF COMPLAINANT : ______________________________________________________________
STUDENT EMPLOYEE APPLICANT PARENT / GUARDIAN
Home Address : ____________________________________________________________
Phone : _____________________________________________________
Date of Claim : _____________________________________________________________________
Date of Incident : _______________________________________________________________________
State Grievance Issue : ( include all pertinent information – who , how , where , when , how often , feelings , witness .)
State Relief Requested :
Please attach any additional information / document necessary .
SIGNATURE OF COMPLAINANT : ____________________________________________________________
SIGNATURE OF TITLE IX COORDINATOR : ________________________________________________________
DATE RECEIVED : ____________________________________________________________________
Forms are available from Title IX Coordinator , Director of Human Resources , Director of Pupil Services , Administrators and Guidance Offices .
Reference : Policy # 5410 Adopted : September 28 , 2006 Revised : July 10 , 2012
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