Policy AC-E-2 Nondiscrimination/Equal Opportunity

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

Issued: date of manual revision

Huerfano School District Re-1, Walsenburg, Colorado