FORM: TITLE VII - Discriminatory Harassment - Non Student

DISCRIMINATORY HARASSMENT-NON STUDENT

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Toledo Public Schools

Discriminatory Harassment Complaint Form

Website: tps.org

File: AC-2-E

1. I am filing this complaint as:
Employee Student Third-Party

2. Complainant(s): Please provide the name of the person(s) who is alleged to be the victim of conduct that could constitute discriminatory harassment.

   a. Name of Parent/Guardian, if Complainant is a minor:

3. Student ID/Employee ID (if applicable):

4. Grade (if applicable):

5. Email Address:

6. Home Address:

7. Telephone No.:

8. School Name/Work Location (if applicable):

9. Please select the type of harassment:

race/color
religion
sex (including pregnancy, sexual orientation, or gender identity)
national origin
age (40 or older)
disability
genetic information (including family medical history)

10. Date(s) of the alleged incident(s):

11. Approximate time(s) of the alleged incident(s):

12. Location of the alleged incident(s):

13. Is there any physical or electronic evidence available? Yes No
If yes, please provide a description in the space provided.

14. Please provide the name of the person(s) who you believe committed the discriminatory harassment.

Complaint: Describe your complaint. Please provide as much information as possible.

 



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