102.E(4) - Discrimination Complaint Form

Date of complaint:
Name of Complainant:
Are you filling out this form for yourself or someone else (please identify the individual if you are submitting on behalf of someone else):
Who or what entity do you believe discriminated against you (or someone else)?
Date and place of alleged incident(s):
Names of any witnesses (if any):

Nature of discrimination alleged (check all that apply):

	Race		Religion
	Color		Sexual Orientation
	National Origin		Age
	Sex		Actual or potential parental, family or marital status
	Disability		Pregnancy or related conditions
	Creed

In the space below, please describe what happened and why you believe that you or someone else has been discriminated against. Please be as specific as possible and attach additional pages if necessary. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

I agree that all of the information on this form is accurate and true to the best of my knowledge.

Signature: _____________________________________ Date: __________________________

I.C. Iowa Code Description

Iowa Code § 216.6 Unfair Employment Practices

Iowa Code § 216.9 Unfair/Discriminatory Practices

Iowa Code § 256.11 DE - Educational Standards

Iowa Code § 280.3 Education Program - Attendance Center Requirements

I.A.C. Iowa Administrative Code Description

281 I.A.C. 12 General Accreditation Standards

U.S.C. - United States Code Description

20 U.S.C. §§ 1221 Education - FERPA - General Provisions

20 U.S.C. §§ 1681 Education - Sex

20 U.S.C. §§ 1701 Education - EEO

29 U.S.C. § 206 Labor - Minimum Wage

29 U.S.C. §§ 794 Labor - Vocation Rehab Rights

42 U.S.C. § 12101 Public Health - Equal Opportunity - Disabilities

42 U.S.C. § 2000d Public Health - Civil Rights - Federally Programs

42 U.S.C. § 2000e Public Health - EEO Civil Rights - Definitions

C.F.R. - Code of Federal Regulations Description

34 C.F.R. Pt. 100 Education - Nondiscrimination for Programs

34 C.F.R. Pt. 104 Education - Nondiscrimination on Basis of Handicap

Cross References Description

101 Educational Philosophy of the School District

104 Anti-Bullying/Harassment Policy

104-R(1) Anti-Bullying/Harassment Policy - Investigation Procedures

104-E(1) Anti-Bullying/Harassment Policy - Complaint Form

104-E(2) Anti-Bullying/Harassment Policy - Witness Disclosure Form

104-E(3) Anti-Bullying/Harassment Policy - Disposition of Complaint Form

401.01 Equal Employment Opportunity

502.03 Student Expression and Student Publications Code

502.03-R(1) Student Expression and Student Publications Code - Regulation

506.01 Education Records Access

506.01-R(1) Education Records Access - Regulation

Cross References Description

506.01-E(1) Education Records Access - Request of Nonparent for Examination or Copies of Education Records

506.01-E(2) Education Records Access - Authorization for Release of Education Records

506.01-E(3) Education Records Access - Request for Hearing on Correction of Education Records

506.01-E(4) Education Records Access - Request for Examination of Education Records

506.01-E(5) Education Records Access - Notification of Transfer of Education Records

506.01-E(6) Education Records Access - Letter to Parent Regarding Receipt of a Subpoena

506.01-E(7) Education Records Access - Juvenile Justice Agency Information Sharing Agreement

506.01-E(8) Education Records Access - Annual Notice

603.01 Basic Instruction Program

802.05 Buildings & Sites Adaptation for Persons with Disabilities

Approved: 9/17/2018, 9/18/2023, 11/18/2024, 12/15/2025, 8/19/2026

Reviewed: 7/22/2026

Revised: 7/22/2026

dawn.gibson.cm… Wed, 06/24/2026 - 20:07