This form is to be filed as a part of the Formal Procedure in order to initiate a complaint of alleged prohibited discrimination or harassment prohibited by the North Colonie Central School District’s Policy Against Harassment (Including Sexual Harassment) and Discrimination Against Students.
Your Name: ________________________________________________________
Address: ___________________________________________________
City: _________________________________ State: _____ Zip Code: __________
Home Phone Number: __________________
Cell Phone Number: __________________
Status: (Check one)
_____ Student
_____ Instructional Staff
_____ Non-Instructional Staff
_____ Other
Basis of discrimination and/or harassment (check as many as are applicable):
_____ Race
_____ Gender
_____ National Origin
_____ Religion
_____ Age
_____ Disability
_____ Sexual Orientation
_____ Marital Status
_____ Retaliation
Time(s) and Date(s) incidents of prohibited discrimination (and/or harassment) took place:
Have you also filed this charge with a Federal, State, or Local Government agency?
_____ Yes
_____ No
Name(s) and office address of the individual who allegedly discriminated against you or harassed you. If more than one, list all.
Name: ________________________________________________________
Office/Location: ________________________________________________________
Describe the incidents which occurred and your reason for concluding that it is/was discriminatory (use extra sheet if necessary).
Describe briefly what you would consider to be appropriate resolution of the conduct described above. (The District at all times retains sole discretion and authority to determine the appropriate disciplinary and/or remedial action to be taken with regard to meritorious complaints. This question should not be
construed in any way to constitute a forfeiture of that discretion or authority.)
Identify all persons who witnessed the incidents described above:
I swear or affirm that I have read the above complaint and that it is true to the best of my knowledge, information and belief.
Complainant’s Signature: ________________________________________________________ Date: __________
Received by: ________________________________________________________ Date: __________