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104. ATTACHMENT
REPORT FORM FOR COMPLAINTS OF DISCRIMINATION
Complainant: __________________________________________________________________
Home Address: ________________________________________________________________
Home Phone: __________________________________________________________________
School Building: _______________________________________________________________
Date of Alleged Incident(s): ______________________________________________________
Alleged discrimination was based on: (circle those that apply)
Race
Color
National Origin
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 I have provided in this complaint is
true, correct and complete to the best of my knowledge.
_____________________________
_______________________
Complainant's Signature
Date
_____________________________
_______________________
Received By
Date