Name of Witness: _________________________________________________________________
Date of interview: _________________________________________________________________
Date of initial complaint: _________________________________________________________________
Name of Complainant ________________________________________________________________
(include whether the
Complainant is a student ________________________________________________________________
or employee):
Date and place of alleged ________________________________________________________________
incident(s):
________________________________________________________________
________________________________________________________________
Nature of discrimination alleged (check all that apply):
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|
Age |
|
Race/Color |
|
|
Disability |
|
Sex |
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|
Religion/Creed |
|
Sexual Orientation |
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Marital Status |
|
Socio-economic Background |
|
|
National Origin/Ethnic Background/Ancestry |
|
|
Description of incident witnessed: ____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Additional information: ____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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
Approved: 9/17/2018, 9/18/2023, 11/18/2024, 12/15/2025
Reviewed: 11/17/2025
Revised: 11/17/2025
