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):
_______________________________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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

 

Complainant’s Signature__________________________________________________________

 

Disposition by Building Administrator:______________________________________________

______________________________________________________________________________

______________________________________________________________________________

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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: ___________________________________________

______________________________________________________________________________

______________________________________________________________________________

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