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104.1-E3 Discrimination Complaint Form


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:

Return this completed form to:

Equity Coordinator/Title IX Coordinator/Affirmative Action Coordinator:
Karla Christian, Chief Officer of Human Resources
319-447-3036 /

Equity Coordinators:
Nathan Wear, Associate Superintendent  (Secondary Level)
319-447-3028 /

Bob Read, Associate Superintendent (Elementary Level)
319-447-3016 /

Special Education/Student Services Equity Coordinator:
Melissa Frick, Executive Director of Student Services
319-447-3663 /

Address: 2999 N 10th Street, Marion, IA 52302
Fax: 319-377-9252

Adopted: 10/17
Reviewed: 3/23
Revised: 6/20; 10/23
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)