Discrimination Reporting Form
Adopted: 9/14/05 (Approved)
Reviewed 10/14/20, 9/14/22
This form may be used by any school employee or student in reporting a complaint of discrimination. This form is affected by the Privacy Act of 1974 and shall be maintained confidential by the District.
The person making the complaint should complete the following form and sign it at the bottom. (If more space is needed, attach an additional papers)
Name:_______________________________________________________________ Date: ______________________________
Address: _____________________________________________________________
Position (employee, student):____________________________________________ School: ______________________________
Date, Time and Place of Incident: ________________________________________________________________________________
_______________________________________________________________________________________________________________
Person(s) Involved: ____________________________________________________________________________________________
_______________________________________________________________________________________________________________
Description of Incident: _________________________________________________________________________________________
_______________________________________________________________________________________________________________
________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Witnesses (if any): ________________________________________________________________________________________________
________________________________________________________________________________________________________________
I confirm that the information reported on this form is accurate.
Signature: _________________________________________________________________
