603.4E - Non-Discrimination on the Basis of Sex or Handicap

Building Level Complaint Form Check (√) area of Complaint

_____Title I Activities in Reading _____Section 504 Handicapped
and Mathematics

_____Title VII Civil Rights _____Title IX Sex Discrimination

Name of Complainant:______________________________Address:______________________

Telephone: ______________________________________

Date that violation or alleged violation occurred: ______________________________________

School:_______________________________________________________________________

Complaint (Please write a brief statement of the complaint, which must be on the area checked above):
_______________________________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

If the complaint is being filed by a representative of the complainant, please sign here:

Complainant’s Signature__________________________________________________________

Disposition by Building Administrator:______________________________________________

______________________________________________________________________________

District Level Complaint Form

Area of Complaint Administrator’s Name Office Phone

Title I Activities ________________________ ___________

Title VII Civil Rights ________________________ ___________

Section 504 Handicapped ________________________ ___________

Title IX Sex Discrimination ________________________ ___________

Date Received _______________________

Persons Attending ______________________________________________________________

______________________________________________________________________________

Disposition by District Complaint Officer: ___________________________________________

______________________________________________________________________________

dawn.gibson.cm… Sun, 07/11/2021 - 15:50