Complaint of employment discrimination, harassment, retaliation, or other violation of School Board Policy 4362
(Please print clearly, complete all lines, and attach additional sheets where necessary)
1. Name, Telephone Number, E-mail Address, and Mailing Address of the Individual Filing the Complaint:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
2. This complaint concerns (check all that apply):
- Discrimination against or the harassment of an individual based on the individual’s legally protected status (e.g., race, sex, age, disability, religion, etc.)
- Inappropriate retaliation taken against an individual, in violation of a law or a District policy
- Workplace harassment, intimidation, etc. that is based on a factor (such as personal animosity) other than a person’s legally protected status
- Other: ____________________________________________________________________________________
3. Does this complaint allege a violation of law or District policy that is based upon, or that has occurred because of, any individual’s legally protected status (e.g., race, sex, age, disability, religion, etc.)?
- No.
- Yes. List each protected status/category that you feel is relevant to the allegations made in this complaint:
________________________________________
________________________________________
________________________________________
4. What is the name of each person who is the alleged target or victim of the improper conduct identified in this complaint?
_________________________________________________
_________________________________________________
_________________________________________________
5. Is each person who you identified in response to Question 4, above, either an employee of the District, a former employee, or an applicant for employment with the District?
- Yes.
- No. Please explain any exceptions. __________________________________________________________
6. Identify the approximate date(s) that the relevant events occurred (or, if the concern is ongoing, identify the date that the events/conduct began). Please use mm/dd/year format.
________________ ________________ ________________
7. To your knowledge and in relation to this complaint, is anyone’s health or safety in imminent danger such that you believe immediate action is needed to alleviate that danger?
- No.
- Yes. Please identify the person(s) and indicate whether you have contacted law enforcement: ____________________________________________________________________________________________
8. Please list any district officials, administrators, or supervisor(s) who you allege are responsible parties in connection with this complaint (if any):
_____________________________________________________________________________________________
9. List any other school district employees who you allege are responsible parties in connection with this complaint (if any):
______________________________________________________________________________________________
10. List any other persons who you allege are responsible parties in connection with this complaint (if any), indicating his/her role (e.g., “John Smith (volunteer coach)”):
______________________________________________________________________________________________
11. Please list known witnesses to key events, indicating whether they are an employee, student, parent, etc. (e.g., “John Smith (employee)”):
_____________________________________________________________________________________________
12. Are you requesting that the District conduct an investigation into this report or complaint?
- Yes.
- No, or at least not at this time.
13. Please describe the basic nature of the complaint/allegations and identify the issue(s) to be resolved (e.g., identify what happened, when it happened, who was involved, whether it is an ongoing problem, etc.):
14. Is there any action you would like the District to consider taking as an interim measure (prior to making any decisions about your report or complaint) that may address safety, prevent additional issues, or enable you to perform your job appropriately?
- No, or at least not at this time.
- Yes (please describe). ____________________________________________________________________
15. Please identify the relief or remedy that you would like the School District to provide in order to resolve this complaint:
16. Have you already attempted to address this matter informally with a supervisor, administrator, or any of the responsible parties?
- No.
- Yes. Please describe those attempts and identify the outcome/response to date: ____________________________________________________________________________________________
____________________________________________________________________________________________
17. Please sign and date this form (for complaints submitted by multiple people, please submit separate forms or add an additional signature page). Your signature is your assurance that the information provided in this complaint is complete and accurate to the best of your knowledge.
____________________________________________________________________
Signature Date
LINES BELOW ARE FOR SCHOOL DISTRICT OFFICE USE ONLY
1. Identify the name and title of the person who received this form on behalf of the School District, and identify the date of receipt:
_____________________________________________________________________________________________________
Name Title Date of Receipt by the District
2. Identify the method of receipt:
- Hand delivery
- U.S. mail
- Email
- Inter-office mail
- Other ___________________________________________
3. By number, identify the items on this form (if any) which were blank at the time the form was initially filed with the District:
________________________________________________
________________________________________________
4. Identify the supervisor(s) or administrator(s) who have been notified of the District’s receipt of this complaint as of the date of receipt: _________________________________________________________________
5. Identify the supervisor or administrator who is assigned primary responsibility for providing an initial administrative response to the complaint: ____________________________________________________________
6. Other Notes:
