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.


Complainant:___________________________________________________________________

Home Address:_________________________________________________________________

Work Address:_________________________________________________________________

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:__________________________ ____________________________________