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 STRIDE Academy 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:

 

 

(Date)