Code: JBA-E 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) ____________________ _________________________________________________________________ Please describe in full detail, the nature of your complaint. Include the names of persons involved, if any. _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________
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 |
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