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Name of Witness:
Date of Interview:
Date of Initial Complaint:
Name of Complainant (include whether the complainant is a student or employee):
Date and Place of Alleged Incident:
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 | |||
Description of incident witnessed (Attach additional sheet, if needed):
Additional Pertinent Information (Attach additional sheet, if needed):
I agree that all the information on this form is accurate and true to the best of my knowledge.
Witness' 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: 104.1; 104.1-R; 104.1-E1-E3; E5
IASB Reference: 102-E(5)