EQUAL EDUCATIONAL OPPORTUNITIES GRIEVANCE PROCEDURE FORM

NAME ____________________________________________________________

ADDRESS _________________________________________________________

COMPLAINT CLAIMS DISCRIMINATION BASED ON: RACE                       _____

 SEX                           _____

 AGE                           _____

 NATIONAL ORIGIN_____

 HANDICAP              _____

PHONE _______________________

DATE OF INCIDENT _______________ LOCATION(S) ____________________

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Please describe in full detail, the nature of your complaint.  Include the names of persons involved, if any. 

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Complainant's Signature _________________________________________

Date Grievance Was Filed ________________________________________

Signature of Civil Rights Compliance Officer/Title IX Coordinator ______________________________________________________________________

 

 

Adoption Date: December 21, 2010

Amended: March 21, 2017