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