0521
Form
REPORT FORM FOR COMPLAINTS OF DISCRIMINATION
Complainant:
Home Address:
Home Phone:
School Building :
Date of Alleged Incident(s):
Alleged harassment was based on: (Check all that apply.)
Race
Gender
Ancestry
Color
Disability
Age
National Origin
Religion
Sexual Orientation
Gender Identity or Expression
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
___ _____________________
Date
__________________________
Received By _____________________
Date
48
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