File: AC-E-2
Nondiscrimination/Equal Opportunity
(Complaint Form)
Date: _______________
Name of complainant: ________________________________________________
School: ____________________________________________________________
Address: ___________________________________________________________
Phone: __________________________
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:
___________________________________________________________________
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
Issued: date of manual revision
Huerfano School District Re-1, Walsenburg, Colorado