4218.11
Discrimination Grievance Form
Any student, parent/guardian, employee or employment applicant who feels that he/she has been discriminated against on the basis of race, color, age, religion, national origin, ancestry, sex, sexual orientation, gender identity or expression, marital status, genetic information, status as a victim of domestic abuse, status as a Veteran, or mental or physical disability (including pregnancy), may discuss and/or file a grievance with either of the Civil Rights Coordinators of the Public Schools. Reporting should take place within 40 calendar days of the alleged discrimination. Civil Rights Coordinators: _____________________
Name of Presenter/Complainant:________________________________________________________________________
Circle One: Employee Employment Applicant Student Parent/Guardian
Home address: ________________________________________________________________________
Telephone _____________________ Date of Claim__________________ Date of Incident_________
1. Statement of Incident/Issue (include all pertinent information: who, how, where, when, how often, feelings, witness).
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2. Please attach any additional information/documentation as necessary.
Signature of Presenter:________________________________________________________________________
Signature of Civil Rights Coordinator:_____________________________________________________________
Date Received
Forms are available from Civil Rights Coordinators', Administrators' and Guidance Offices.