Discrimination/Harassment Complaint Form - Title IX, Affirmative Action, and/or Section 504 - Delsea Regional High School District
The Delsea High School District does not discriminate in its employment practices, business action, and/or
educational opportunities because of race, creed, color, national origin, ancestry, marital status, sex, or handicap.


Title IX Coordinator and Affirmative Action Officer: Michael Nicholson, Vice Principal
P.O. Box 405, 242 Fries Mill Road, Franklinville, NJ 08322
(856) 694-0100, Extension 241 (phone) * (856)694-4417 (fax)

504 Coordinator: Jackie Scerbo, Director of CST and Special Services
P.O. Box 405, 242 Fries Mill Road, Franklinville, NJ 08322
(856) 694-0100, Extension 241 (phone) * (856)694-4417 (fax)


** PLEASE BE ADVISED THAT ALL INFORMATION DISCLOSED IS CONFIDENTIAL AND CAN BE DISCUSSED IN PERSON**
Please select the applicable Section regarding the type of Complaint you are filing. *
First Name *
Your answer
MI
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Last Name *
Your answer
Full Address: *
Please include city and zip code
Your answer
Phone Number: *
Your answer
Department: *
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Title:
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Location: *
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Email: *
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Supervisor's Name: *
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Preferred method of contact: *
Discrimination or Harassment Based on:
Check all that apply
Race
Creed
Gender
Religion
Age
National Origin
Color
Affectional or Sexual Orientation
Ancestry
Pregnancy
Sexual Harassment
Military Service
Marital/domestic partnership/civil union status
Disability
Retaliation for having previously filed an affirmative action complaint
Gender identification
Genetic Information
Accused Information: *
Please include full name, title, and location
Your answer
Discrimination History *
Please include full name, title, and location. Provide first date of this particular act of discrimination. Include any witness information (for the present alleged incident).
Your answer
Have you reported this allegation of harassment or discrimination to any supervisor or administrator? If so, please indicate to whom, when, and what was the result:
Your answer
Nature of Charge: In detail, explain the Nature of the Charge, including name(s) of person(s) involved: *
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Resolution: What corrective action are you seeking? *
Your answer
Have you ever filed a Discrimination/Harassment Complaint in the past? If so, please provide the following information (Type of complaint; Date Filed; Substantiated or Unsubstantiated):
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Certification: I certify that the foregoing information is correct to the best of my knowledge: *
Please type your full name and today's date below for your electronic signature.
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