5010F Form - Discrimination Complaint Form

You may submit the complaint form anonymously.  While we will attempt to investigate anonymous complaints, our ability to find resolution for your concern may be hindered by our inability to contact you for additional information.
Submitted by
Under provisions of RCW 28A.642.010, discrimination in Washington public schools on the basis of race, creed, religion, color, national origin, honorably discharged veteran or military status, sexual orientation including gender expression or identity, the presence of any sensory, mental, or physical disability, or the use of a trained dog guide or service animal by a person with a disability if prohibited.  In accordance with Procedure 5010, the district will respond to anyone who feels aggrieved on the basis of any of the above forms of discrimination.
Under provisions of RCW 28A.640.020, schools are required to eliminate sexual discrimination as it applies to employment.  In accordance with Procedure 5011, the district will respond to anyone who feels aggrieved on the basis of sex discrimination in employment. 
It is recommended that you attempt to resolve your concern with those school employees who are responsible for the area in which you feel aggrieved.  If that process does not result in a satisfactory solution, complete all the sections of the form and send it to “Compliance Officer, Human Resources.”
Describe in your own words the grounds of your complaint, including all names, dates, and places which will help the district understand the situation.  Use additional pages if necessary.
Has this matter been discussed with the supervisor of the employee involved?  c Yes        c No
If yes, to whom have you spoken?  _______________________________________________________________________
Describe the results of your discussion(s).  Use additional pages in necessary.
I understand that the school district may request additional information from me about this complaint.
Date Submitted:  _______________________________
Rev 11/2018 sb