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.
I have been discriminated against based on (choose one or more):
[my disability] / [a record of my disability] / [being regarded as having a disability]
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)