INDEPENDENT SCHOOL DISTRICT NO. 599

STUDENT DISABILITY DISCRIMINATION GRIEVANCE REPORT FORM

General Statement of Policy Prohibiting Disability Discrimination

Independent School District No. 599 maintains a firm policy prohibiting all forms of discrimination on the basis of a disability. All persons are to be treated with respect and dignity. Discrimination on the basis of a disability will not be tolerated under any circumstances.

Complainant:___________________________________________________________________

Home Address:_________________________________________________________________

Work Address:_________________________________________________________________

Home Phone:___________________________ Work Phone:____________________________

I have been discriminated against based on (choose one or more):

[my disability] / [a record of my disability] / [being regarded as having a disability]

because_______________________________________________________________________

_____________________________________________________________________________

Date of alleged incident(s):________________________________________________________

Name of person you believe discriminated against you or another person:____________________

______________________________________________________________________________

If the alleged discrimination was toward another person, identify that person:_________________

______________________________________________________________________________

Describe the incident(s) as clearly as possible, including such things as: any verbal statements; what, if any, physical contact was involved; etc. (attach additional pages if necessary):_________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Location of the incident(s):________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

List any witnesses that were present:________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

This complaint is filed based on my honest belief that ________________________ has discriminated against me or another person based on a disability. I hereby certify that the information I have provided in this complaint is true, correct, and complete to the best of my knowledge and belief.

____________________________________ ____________________________________

(Complainant Signature) (Date)

Received by:__________________________ ____________________________________

(Date)