INDEPENDENT SCHOOL DISTRICT NO. 2176
UNLAWFUL SEX DISCRIMINATION TOWARD A STUDENT
General Statement of Policy Prohibiting Unlawful Sex Discrimination Toward a Student
Independent School District No. 2176 maintains a firm policy prohibiting all forms of unlawful sex discrimination. All students are to be treated with respect and dignity. Unlawful sex discrimination by any teacher, administrator or other school personnel will not be tolerated under any circumstances.
Home Phone:___________________________ Work Phone:____________________________
Date of Alleged Incident(s):_______________________________________________________
Name of person you believe unlawfully discriminated toward you or a student on the basis of sex:__________________________________________________________________________
If the alleged unlawful sex discrimination was toward another person, identify that person:_____
Describe the incident(s) as clearly as possible, including such things as: what force, if any, was used; any verbal statements (i.e. threats, requests, demands, etc.); what, if any, physical contact was involved; etc. (Attach additional pages if necessary):_______________________________
Where and when did the incident(s) occur:___________________________________________
List any witnesses that were present:________________________________________________
This complaint is filed based on my honest belief that ________________________ has unlawfully discriminated against me or a student on the basis of sex. 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:__________________________ ____________________________________