EDUCATIONAL PHILOSOPHY
Series 100
Policy Title: Discrimination Complaint Form Code No. 102E4
Date of complaint: ______________________________________________________________
Name of Complainant: ___________________________________________________________
Are you filling out of this form for yourself or someone else (please identify the individual if you are submitting on behalf of someone else) ___________________________________________________________________________________________________________________________________________________________
Who or what entity do you believe discriminated against you (or someone else)? ____________________________________________________________________________________________________________________________________________________________
Date and place of alleged incident(s): ____________________________________________________________________________________________________________________________________________________________
Names of any witnesses (if any): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Nature of discrimination alleged (check all that apply):
____ Age ____ Sex
____ Disability ____ Sexual Orientation
____ Socio-economic Background ____ Marital Status
____ Race/Color ____ National Origin/Ethnic Background/Ancestry
In the space below, please describe what happened and why you believe that you or someone else has been discriminated against. Please be as specific as possible and attach additional pages if necessary.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: ___________________________________________
Date: _______________________________________________
Date of Adoption/Review/Revision:
July 2003
July 2006
July 2007
July 2009
July 2009
July 2012
July 2015
March 2017
October 2018
September 2020
May 2024
April 2025
102E4 Discrimination Complaint Form Pg. 2
