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Today's Date:
Name of Complainant (include whether the complainant is a student or employee):
Date of Initial Complaint:
Date and Place of Alleged Incident:
Name of Respondent (include whether the respondent is a student/employee/volunteer):
Nature of alleged discrimination (Check all that apply):
| Age | Martial Status | ||
| Color | Sex | ||
| Creed | Sexual Orientation | ||
| National Origin | Gender Identity | ||
| Race | Political Party Preference | ||
| Religion | Political Beliefs | ||
| Ancestry | Socioeconomic Status | ||
| Physical Attributes | Familial Status | ||
| Genetic Information | Pregnancy | ||
| Physical/Mental Ability or Disability | Military Status | ||
| Other - Please Specify | |||
Summary of Investigation:
I agree that the information on this form is accurate and true to the best of my knowledge.
Equity Coordinator's Signature:
Date:
Adopted: 10/17
Reviewed: 3/23
Revised: 6/20
Related Policy: 103.1; 103.1-R; 103.1-E1-E3; 104.1; 104.1-R; 104.1-E1-E4
IASB Reference: 102-E(6)