Complaint Form - Amazon S3



-35009802005Franklin Township Community Schools Corporation COMPLAINT FORM Harassment Complaint (refer to School Board Policy A100 and Employee Handbooks) Disability Discrimination Complaint – (Refer to School Board Policy A100) Public Complaint (refer to School Board Policy A100) Racial Discrimination Complaint - Title VI (refer to School Board Policy A100) Sex Discrimination Complaint - Title IX (refer to School Board Policy A100) The purpose of this form is to assist you in filing a complaint with the Franklin Township Community Schools. You are not required to use this form; a written statement with the same information is sufficient. Complaints are to be submitted to the Human Resource Director, who serves as the District Complaint Coordinator. District Complaint CoordinatorFranklin Township Community School Corp.6141 S. Franklin RoadIndianapolis, IN 46259317-803-5007Email: jill.britt@Serving as an alternate complaint coordinator is the Assistant Superintendent.Your Contact InformationName: _______________________________________________________________________ Position in District: ______________________________________________________________ Department (if applicable): ______________________ Building Name: ____________________ Phone: Home: (____) ____________ Work: (____) ____________ Mobile: (____) ____________ Email: ________________________________________________________________________ Person(s) harassed or discriminated against, if different from above: Name:________________________________________________________________________ Connection to person and / or District: ______________________________________________ _____________________________________________________________________________ Please list potential witness(es) if known: _______________________________ _____________________________________________________________________________ _____________________________________________________________________________ Please indicate below the basis for which you believe these discriminatory or harassing actions were taken (e.g., “Race: African American” or “Sex: Female”). Race / Color: ______________________________________________________________ National Origin: ____________________________________________________________ Sex: _____________________________________________________________________ Age: ____________________________________________________________________ Disability: ________________________________________________________________ Other: ___________________________________________________________________ To your best recollection, on what date(s) did the alleged discrimination and or harassment take place? Earliest date of discrimination and or harassment: _____________________________________________________________________________ Most recent date of discrimination and or harassment: _____________________________________________________________________________ Please explain as clearly as possible, the details of the harassing or discriminating actions. Include all names of those involved, including individuals who witnessed the actions. Be sure to include how other persons were treated differently. (Please use additional sheets if necessary and attach a copy of written materials pertaining to your allegations.) ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Please list below any persons (witnesses, fellow employees, supervisors, or others) if known, who we may contact for additional information to support or clarify your complaint. Name(s):______________________________________________________________________ _____________________________________________________________________________ Do you have any other information that you think is relevant to our investigation of your allegations? If yes, please include below. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ What remedy are you seeking for the alleged discrimination or harassment? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Please sign and date this document form below. I wish to file a formal complaint. I do not wish to file a formal complaint, but wish to provide documentation of the incident(s). I understand that the allegations I have documented will be investigated even though I am not filing a formal complaint. ___________________________________________________ _________________ Printed Name Date _______________________________ Signature ................
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