Discrimination/harassment Complaint Form printable pdf download

Uniform Complaint Procedure

Discrimination/Harassment Complaint Reporting Form

In accordance with the District’s Uniform Complaint Procedures (5 CCR 4620)

each school district shall follow uniform complaint procedures when addressing

complaints alleging unlawful discrimination against any protected group.

Protected groups are enumerated by Education Code §§ 200 and 220 and

Government Code §11135, and include actual or perceived sex, sexual

orientation, gender, ethnicity, race, ancestry, national origin, religion, color,

mental or physical disability, and age, as well as association with member of a

protected class.

I. Contact Information:

Name: ______________________________________________________________________

Address: ____________________________________________________________________

City: ____________________________________ Zip: _______________________________

Home Phone: ___________________________ Work or Cell Phone: _______________

II. Complainant

You are filing this complaint on behalf of: _____________________________________

 yourself

 your child or a (student)

 another student

 a group

III. School Information

School Name: _________________________________

Principal’s Name: ______________________________

Address: _______________________________________ City: _______________________

IV. Nature of Discrimination or Harassment:

Please check the following box(s), based on the type(s) of harassment you

experienced, including your actual or perceived:

 Sexual

 National origin

 Age

orientation

 Religion

 Association with

 Gender

 Color

any of these

 Ethnicity

 Ancestry

Discrimination/harassment Complaint Form