Uniform Complaint Procedure Discrimination/Harassment Complaint Reporting Form for Students

In accordance with the state's Uniform Complaint Procedures (5 CCR 4620) each school shall follow uniform complaint procedures when addressing complaints alleging unlawful discrimination, harassment, intimidation and bullying against any protected group. Protected groups are enumerated by Education Code §200 and §220. Additionally, it is the policy of the State of California, pursuant to Section 200, that all individuals shall enjoy freedom from discrimination and/or harassment of any kind in the educational institutions of the state. This also includes sexual harassment, which is a form of sexual discrimination (Education Code § 231.5).

I. Contact Information

Name:required

Address:

Phone Numberrequired

Email Address

II. Complainant

You are filing this complaint on behalf of:*

yourself your child or a (student) another student a group

III. School Information

School namerequired

Principal's Name

Address

City

IV. Basis of Complaint

V. Details of Complaint

Please answer the following questions to the best of your ability.

Please describe the type of incident(s) you experienced that led to this complaint, including the events or actions, in as much detail as possible:required

List the individuals involved in the incident(s) complaint of:

List any witnesses to the incident(s):

Describe the location where the incident (s) occurred:required

Please list all the date(s) and times when the incident(s) occurred or when the alleged acts first came to your attention:

What steps, if any, have you taken to resolve this issue before filing a complaint?