INDEPENDENT SCHOOL DISTRICT NO. 84
STUDENT DISABILITY DISCRIMINATION GRIEVANCE REPORT FORM
General Statement of Policy Prohibiting Disability Discrimination
Independent School District No. 84 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:__________________________ ____________________________________
(Date)
