Uniform Complaint Form
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Email *
Name of Person Filing Complaint (Last, First, M.I.) *
Address (Include City, State, Zip Code) *
Phone Number (Include Work Phone Number) *
Email Address *
Name of Person You Are Complaining Against (Last, First, M.I.) *
Job Title, Location & Phone Number of the Person You Are Complaining About
Nature of Complaint: (Protected Basis) *
State What Specific Federal or State Statute or Board Policy, Rule or Regulation you Believe was Violated, Misapplied or Misinterpreted by the Person(s) Identified in #2 Above. *
What is the Most Recent Date you Were Discriminated Against or You Were Adversely Affected by the Person(s) Identified in #2Above *
If the Above Date is More Than 180 Days Ago, Please Explain Why you Waited until Now to File Your Complaint *
When Did the Alleged Discrimination or Adverse Action Begin? *
When Did You First Become Aware That The Treatment, Act, or Decision Was Discriminatory, Illegal or Against Board Policy, Rule or Regulation? *
How Did You First Become Aware That the Treatment, Act, or Decision Was Discriminatory, Illegal, or Against Board Policy, Rule or Regulation? *
In Your Own Words, Describe the Incident(s), Date Incident(s) Occurred, and Person(s) Who Were Present When Each Incident Occurred *
Have You Tried to Resolve Your Complaint with the Person Identified in #2, Your Immediate Supervisor, The School Principal or Program Administrator? *
If Yes, Who Did You Speak To? (Name, Job Title, Location, Date of Discussion and What Was the Result of the Discussion? *
List the Name, Address and Phone Number of Your Witness, and State What Relevant Information Each of Your Witnesses Will Be Able to Provide:  Witness #1 *
Witness #2      Name, Address and Phone Number of Your Witness, and State What Relevant Information                                                                                
Witness #3     Name, Address and Phone Number of Your Witness, and State What Relevant Information                                                                                        
What Do You Expect to Happen As A Result of This Complaint?
I understand that the Board of Education, Affirmative Action Office, and/or designee(s) assigned to investigate the complaint may request from me further information about this complaint and, if such information is available, I shall present it upon request.  I also understand that a copy of this complaint will be given the opportunity to respond in writing to this complaint. An exception to this would be under certain circumstances, such as where there is clear and convincing evidence that you would be in danger of retaliation if the person whom this complaint is being made received a copy of this complaint.   I also understand that, if a hearing is held on this complaint by the Board of education, such hearing will be held in Executive Session with the press and public excluded and that I will be informed of the time, date and place such hearing will be held.    I Certify under penalty of perjury that the forgoing is true and correct.   *
Required
Executed on (Day, Date and year), (add City and State) *
Signature: Please write Full Name and Date *
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