4118.11 Form

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.