File:  AC-E-2

 

 

 

 

 

Nondiscrimination/Equal Opportunity

(Complaint Form)

 

Date:  _______________

 

Name of complainant:  ________________________________________________

 

School:  ____________________________________________________________

 

Address:  ___________________________________________________________

 

Phone:  __________________________

 

Summary of alleged unlawful discrimination or harassment:

 

___________________________________________________________________

 

___________________________________________________________________

 

___________________________________________________________________

 

___________________________________________________________________

 

 

Name(s) of individual(s) allegedly engaging in prohibited conduct:

 

___________________________________________________________________

 

___________________________________________________________________

 

 

Date(s) alleged prohibited conduct occurred:

 

___________________________________________________________________

 

 

Name(s) of witness(es) to alleged prohibited conduct:

 

___________________________________________________________________

 

If others are affected by the possible unlawful discrimination or harassment, please give their names:

 

___________________________________________________________________

 

 

Your suggestions regarding resolving the complaint:  _________________________

 

___________________________________________________________________

 

___________________________________________________________________

 

Please describe any corrective action you wish to see taken with regard to the alleged unlawful discrimination or harassment. You may also provide other information relevant to this complaint.

 

__________________________________________________________________

 

___________________________________________________________________

 

___________________________________________________________________

 

___________________________________________________________________

 

 

 

_________________________________                  ________________________

Signature of complainant                                                        Date

 

_________________________________                  ________________________

Signature of person receiving complaint                                Date

 

 

Adopted: February 27, 2018