EQUAL EDUCATIONAL OPPORTUNITY - DISCRIMINATION COMPLAINT FORM
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Date of complaint:
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Name of Complainant:
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_____________________________________________________ |
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Are you filling out this form for yourself or someone else (please identify the individual if you are submitting on behalf of someone else):
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_____________________________________________________
_____________________________________________________ |
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Who or what entity do you believe discriminated against, harassed, or bullied you (or someone else)?
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_____________________________________________________ |
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Date and place of alleged incident(s): |
_____________________________________________________
_____________________________________________________
_____________________________________________________ |
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Names of any witnesses (if any): |
_____________________________________________________ |
Nature of discrimination, harassment, or bullying alleged (check all that apply):
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Age |
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Race/Color |
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Disability |
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Sex |
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Religion/Creed |
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Sexual Orientation |
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Marital Status |
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Socio-economic Background |
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National Origin/Ethnic Background/Ancestry |
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In the space below, please describe what happened and why you believe that you or someone else has been discriminated against, harassed, or bullied. Please be as specific as possible and attach additional pages if necessary.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: _____________________________________ Date: __________________________
Cross Reference:
101 Educational Philosophy of the School District
104 Anti-Bullying/Harassment Policy
104R1 Anti-Bullying/Harassment Policy - Investigation Procedures
104E1 Anti-Bullying/Harassment Policy - Complaint Form
104E2 Anti-Bullying/Harassment Policy - Witness Disclosure Form
104E3 Anti-Bullying/Harassment Policy - Disposition of Complaint Form
401.01 Equal Employment Opportunity
502.03 Student Expression and Student Publications Code
502.03R1 Student Expression and Student Publications Code - Regulation
506.01 Education Records Access
506.01R1 Education Records Access - Regulation
506.01E1 Education Record Access - Request of Nonparent for Examination or Copies of Education Records
506.01E2 Education Records Access - Authorization for Release of Education Records
506.01E3 Education Records Access - Request for Hearing on Correction of Education Records
506.01E4 Education Records Access - Request for Examination of Education Records
506.01E5 Education Records Access - Notification of Transfer of Education Records
506.01E6 Education Records Access - Letter to Parent Regarding Receipt of a Subpoena
506.01E7 Education Records Access - Juvenile Justice Agency Information Sharing Agreement
506.01E8 Education Records Access - Annual Notice
603.01 Basic Instruction Program
603.04 Multicultural/Gender Fair Education
802.05 Buildings & Sites Adaptation for Persons with Disabilities
Approved: 8/8/2016 Reviewed: 02/24/2026 Revised: 02/24/2026