Embedded Files
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 ______________________________________________________________________
Date filed with the WDE if complaint is in regards to the National School Nutrition Program: _______________________
Adoption Date: December 21, 2010
Amended: March 21, 2017
February 21, 2023
WSBA Revised 11/30/10; 01/18/23
Report abuse