INDEPENDENT SCHOOL DISTRICT NO. ______

UNLAWFUL SEX DISCRIMINATION TOWARD A STUDENT

General Statement of Policy Prohibiting Unlawful Sex Discrimination Toward a Student

Independent School District No. ______ maintains a firm policy prohibiting all forms of unlawful sex discrimination.  All students are to be treated with respect and dignity. Unlawful sex discrimination by any teacher, administrator or other school personnel will not be tolerated under any circumstances.

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

Date of Alleged Incident(s):_______________________________________________________

Name of person you believe unlawfully discriminated toward you or a student on the basis of sex:__________________________________________________________________________

If the alleged unlawful sex discrimination was toward another person, identify that person:_____
_____________________________________________________________________________

Describe the incident(s) as clearly as possible, including such things as: what force, if any, was used; any verbal statements (i.e. threats, requests, demands, etc.); what, if any, physical contact was involved; etc.  (Attach additional pages if necessary):_______________________________
_____________________________________________________________________________
_____________________________________________________________________________

Where and when did the incident(s) occur:___________________________________________
_____________________________________________________________________________

List any witnesses that were present:________________________________________________
_____________________________________________________________________________

This complaint is filed based on my honest belief that ________________________ has unlawfully discriminated against me or a student on the basis of sex.  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:__________________________	____________________________________