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DA
TE:
NAME OF PERSON FILI
NG THIS COMPLAINT:
1. NAME: ☐MR. ☐MRS. ☐MS.
(LAST) (FIRST) (MI)
PUPIL’S NAME
AD
DRESS
CI
TY & STATE
PH
ONE: HOME CELL
(AREA CODE) (AREA CODE)
2. NAME OF PERSON YOU ARE COMPLAINING AGAINST:
NAME: ☐MR. ☐MRS. ☐MS.
(LAST) (FIRST) (MI)
JOB TITLE
LO
CATION
PHONE: WORK
(AREA CODE)
3. NATURE OF COMPLAINT:
CHECK ONE OR MORE AND SPECIFY EACH ITEM CHECKED
☐ ACTUAL OR PERCEIVED
SEX ☐ AGE
☐ MALE ☐ FEMALE ☐ RACE
☐ ANCESTRY ☐ COLOR
☐ ETHNICITY ☐ NATIONAL ORIGIN
☐ RELIGION ☐ SEX (TITLE IX)
☐
SEXUAL ORIENTATIO
N ☐ PREGNANCY
☐ DISABILITY (MENTAL OR PHYSICAL) ☐ RETALIATION
☐ ETHNIC GROUP IDENTIFICATION ☐ MARITAL STATUS
☐ GENDER (IDENTITY OR EXPRESSION) ☐ HARASSMENT
☐ MALE ☐ FEMALE ☐ INTIMIDATION
☐ MEDICAL CONDITION ☐ BULLYING
(CANCER OR GENETIC CHARACTERISTICS)
☐
UNLAWFUL REQUIREMENT OF FEES
RIALTO UNIFIED SCHOOL DISTRICT
UNIFORM COMPLAINT FORM
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☐ PERSON’S ASSOCIATION WITH A PERSON OR ☐ VIOLATION OF SCHOOL SAFETY PLAN
GROUP WITH ONE OR MORE OF THE ABOVE-
NOTED REQUIREMENTS ACTUAL OR PERCEIVED
CHARACTERISTICS
4. WHAT IS THE MOST RECENT DATE YOU WERE DISCRIMINATED AGAINST OR YOU WERE
ADVERSELY AFFECTED BY THE PERSON(S) IDENTIFIED IN #2 ABOVE?
5. IF THE ABOVE DATE IS MORE THAN 180 DAYS AGO, PLEASE EXPLAIN WHY YOU WAITED UNTIL
NOW TO FILE YOUR COMPLAINT.
6. WHEN DID THE ALLEGED DISCRIMINATION OR ADVERSE ACTION BEGIN?
7. WHEN DID YOU FIRST BECOME AWARE THAT THE TREATMENT, ACT, OR DECISION WAS
DISCRIMINATORY, ILLEGAL OR AGAINST BOARD POLICY, RULE OR REGULATION?
8. HAVE YOU TRIED TO RESOLVE YOUR COMPLAINT WITH THE PERSON IDENTIFIED IN #2, HIS/HER
IMMEDIATE SUPERVISOR, THE SCHOOL PRINCIPAL, OR PROGRAM ADMINISTRATOR?
☐ YES ☐ NO
IF YES, WHO DID YOU SPEAK TO?
NAME:
JOB TITLE:
LOCATION:
DATE OF DISCUSSION:
WHAT WAS THE RESULT OF THE DISCUSSION?
9. PLEASE DESCRIBE THE INCIDENT(S) OF HARASSMENT OR DISCRIMINATION THAT YOU EXPERIENCED,
INCLUDING PLACE WHERE INCIDENT(S) OCCURRED, AND PERSONS WHO WERE
PRESENT WHEN EACH INCIDENT OCCURRED. (Attach additional pages if necessary)
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10. WHAT DO YOU EXPECT TO HAPPEN AS A RESULT OF THIS COMPLAINT?
11. LIST THE NAME, ADDRESS AND PHONE NUMBER OF YOUR WITNESSES, AND STATE WHAT RELEVANT
INFORMATION EACH OF YOUR WITNESSES WILL BE ABLE TO PROVIDE. (Attach additional pages if necessary)
WITNESS #1
NAME:
ADDRESS:
PHONE:
STATE WHAT INFORMATION THIS WITNESS WILL BE ALE TO PROVIDE.
WITNESS #2
NAME:
ADDRESS:
PHONE:
STATE WHAT INFORMATION THIS WITNESS WILL BE ALE TO PROVIDE.
WITNESS #3
NAME:
ADDRESS:
PHONE:
STATE WHAT INFORMATION THIS WITNESS WILL BE ALE TO PROVIDE.
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I understand that the Board of Education, Personnel Office, and/or designee(s) assigned to investigate the
complaint may request from me further information about this complaint and, if such information about this
complaint and, if such information is available, I shall present it upon request.
I also understand that a copy of this complaint will be given by the Personnel Office and/or designee(s) against
whom this complaint is being made who will be given the opportunity to respond in writing to this complaint.
I also understand that if a hearing is held on this complaint by the Board Of Education, such hearing will be held
in Closed Session with the press and public excluded and that I will be informed of the time, date and place
such hearing will be held.
I certify under penalty of perjury that the foregoing is true and correct.
Executed this day of
20 , at , California
Signature Date
PLEASE SUBMIT COMPLETED FORM TO:
Rialto Unified School District
Personnel Services
182 E. Walnut Avenue
Rialto, CA 92376
Revised 9/25/13
