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 sexual harassment. (Note: Investigator will use investigation procedures consistent with allegations of sex-based discrimination and/or sexual 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:

_______________________________________________________________________________

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.

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_________________________________                                              ________________________
Signature of complainant                                                                             Date

_________________________________                                              ________________________
Signature of person receiving complaint                                                    Date

(Issue date)  ______________________

Adopted:  September 17, 2020