(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:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
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
Issued: July 23, 2015
Revised: September 26, 2024