INDEPENDENT SCHOOL DISTRICT NO. 4142-07

 

STUDENT DISABILITY DISCRIMINATION GRIEVANCE REPORT FORM

 

General Statement of Policy Prohibiting Disability Discrimination

 

Independent School District No. 4142-07 maintains a firm policy prohibiting all forms of discrimination on the basis of a disability. All persons are to be treated with respect and dignity. Discrimination on the basis of a disability will not be tolerated under any circumstances.

 

Complainant:___________________________________________________________________

Home Address:_________________________________________________________________

Work Address:_________________________________________________________________

Home Phone:___________________________ Work Phone:____________________________

 

I have been discriminated against based on (choose one or more):

 

[my disability]  /  [a record of my disability]  /  [being regarded as having a disability]

 

because_______________________________________________________________________

_____________________________________________________________________________

 

Date of alleged incident(s):________________________________________________________

 

Name of person you believe discriminated against you or another person:____________________

______________________________________________________________________________

 

If the alleged discrimination was toward another person, identify that person:_________________

______________________________________________________________________________

 

Describe the incident(s) as clearly as possible, including such things as: any verbal statements; what, if any, physical contact was involved; etc. (attach additional pages if necessary):_________

______________________________________________________________________________

 

______________________________________________________________________________

______________________________________________________________________________

 

Location of the incident(s):________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

List any witnesses that were present:________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

 

 

This complaint is filed based on my honest belief that ________________________ has discriminated against me or another person based on a disability. I hereby certify that the information I have provided in this complaint is true, correct, and complete to the best of my knowledge and belief.

 

____________________________________            ____________________________________

(Complainant Signature)                                                                               (Date)

 

Received by:__________________________           ____________________________________