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JBA-E Policy -Equal Educational Opportunities Grievance Procedure Form

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
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ptefertiller@sublette9.org,
Feb 21, 2013, 9:21 AM
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