Date of Complaint:
Name of Complainant:
Are you filing out this form for yourself or someone else?
(Please identify the individual if you are submitting this form on behalf of someone else):
Who or what entity do you believe discriminated against you (or someone else)?
Date and Place of Alleged Incident:
Names of Witnesses:
Nature of alleged discrimination (Check all that apply):
|National Origin||Gender Identity|
|Race||Political Party Preference|
|Physical Attributes||Familial Status|
|Physical/Mental Ability or Disability||Military Status|
|Other - Please Specify|
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 the information on this form is accurate and true to the best of my knowledge.
Return this completed form to:
Equity Coordinator/Title IX Coordinator/Affirmative Action Coordinator:
Karla Christian, Chief Officer of Human Resources
319-447-3036 / kchristian@Linnmar.k12.ia.us
Mr. Nathan Wear, Associate Superintendent
319-447-3028 / nathan.wear@Linnmar.k12.ia.us
Address: 2999 N 10th Street, Marion, IA 52302
Related Policy: 103.1; 103.1-R; 103.1-E1-E3; 104.1; 104.1-R; 104.1-E1-E2; E4-E5
IASB Reference: 102.E4