102.E(4) - Discrimination Complaint Form

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):

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:   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
                                         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
                                         603.04  Multicultural/Gender Fair Education
                                         802.05  Buildings & Sites Adaptation for Persons with Disabilities