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Date of Complaint:
Name of Complainant:
Are you filling 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):
| Age | Marital 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 | |||
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.
Complainant's Signature:
Date:
Return this completed form to:
Equity Coordinator/Title IX Coordinator/Affirmative Action Coordinator:
Karla Christian, Chief Human Resources Officer
319-447-3036 / kchristian@Linnmar.k12.ia.us
Equity Coordinator:
Nathan Wear, Associate Superintendent
319-447-3028 / nathan.wear@Linnmar.k12.ia.us
Special Education/Student Services Equity Coordinator:
Melissa Frick, Executive Director of Student Services
319-730-3663 / melissa.frick@Linnmar.k12.ia.us
Address: 3556 Winslow Road, Marion, IA 52302
Fax: 319-403-8008
Adopted: 10/17
Reviewed: 3/23
Revised: 6/20; 10/23; 9/24
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-E(4)