File:  AC-E-2 - Nondiscrimination/Equal Opportunity

(Complaint Form)

Date:  _______________

Name of complainant:  _________________________________________________

School:  ____________________________________________________________

Address:  ___________________________________________________________

Phone:  __________________________

[ ]  Please check here for allegations of sex-based discrimination and/or sex-based harassment. (Note: Investigator will use investigation procedures consistent with allegations of sex-based discrimination and/or sex-based harassment).

Summary of alleged unlawful discrimination or harassment:

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

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Date(s) alleged prohibited conduct occurred:

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

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

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Your suggestions regarding resolving the complaint:  ___________________________

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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.

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Signature of complainant                                   Date

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Signature of person receiving complaint             Date

Issued:  July 23, 2015

Revised:  September 26, 2024