INDEPENDENT SCHOOL DISTRICT NO. __545__

STUDENT DISABILITY DISCRIMINATION GRIEVANCE REPORT FORM

General Statement of Policy Prohibiting Disability Discrimination

Independent School District No. _545_ maintains a firm policy prohibiting all forms of discrimination on the basis of a disability.  All persons are to be treated with respect and dignity. Discrimination on the basis of a disability will not be tolerated under any circumstances.

Complainant:___________________________________________________________________
Home Address:_________________________________________________________________
Work Address:_________________________________________________________________
Home Phone:___________________________ Work Phone:____________________________

I have been discriminated against based on (choose one or more):

[my disability]   /   [a record of my disability]   /   [being regarded as having a disability]

because_______________________________________________________________________
_____________________________________________________________________________

Date of alleged incident(s):________________________________________________________

Name of person you believe discriminated against you or another person:____________________
______________________________________________________________________________

If the alleged discrimination was toward another person, identify that person:_________________
______________________________________________________________________________

Describe the incident(s) as clearly as possible, including such things as: any verbal statements; what, if any, physical contact was involved; etc. (attach additional pages if necessary):_________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Location of the incident(s):________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

List any witnesses that were present:________________________________________________
_____________________________________________________________________________
______________________________________________________________________________

This complaint is filed based on my honest belief that ________________________ has discriminated against me or another person based on a disability.  I hereby certify that the information I have provided in this complaint is true, correct, and complete to the best of my knowledge and belief.

____________________________________	____________________________________
(Complainant Signature)				(Date)

Received by:__________________________	____________________________________
							(Date)