File:  JBA-F

 

REPORT OF DISCRIMINATION

 

 

Name of Complainant:

 

Student’s School and Class:

 

Address and Phone Number:

 

Date(s) of Alleged Discrimination:

 

Name of person(s) you believe discriminated against you or others:

 

Please describe in detail the incident(s) of alleged discrimination, including where and when the incident(s) occurred.   Please name any witnesses that may have observed the incident(s).  Attach additional pages if necessary.

 

 

 

 

 

 

 

 

 

 

Please describe any past incidents that may be related to this complaint.

 

I certify that the information provided in this report is true, correct and complete to the best of my knowledge.

 

 

________________________­­_________________________________________

Signature of Complainant                                                                            Date

 

 

Complaint Received By:                 ______________________________________

                                                            Compliance Officer                               Date

 

 

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