Discrimination/harassment Complaint Form
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1Wakulla County School Board
Discrimination/Harassment Complaint Form
The School Board seeks to provide a work environment free of discrimination and harassment on the basis of race, color,
religion, sex, national origin, disability, or marital status.
This form shall be completed by the Complainant and presented or forwarded to the Equity Coordinator/Human
Resources. A copy should be retained by the Complainant.
Section I:
Complainant Information
Date:
Name:
Address:
City:____________________________________
State:___________________
Zip_______________
Phone (______)_________________ Work Phone (_____) ________________ Cell Phone (______)____________________
The best time to contact me is:__________________
A.M.
P.M. on my
Home phone
Work phone
Cell phone
Level of Complaint I ___________________________________________________________________
(Head of Department)
II
Robert Pearce
III:
Karen J. Wells
(Assistant Superintendent)
(Equity Coordinator)
Alleged Basis of Discrimination
Race
Color
Religion
Sex
National Origin
Age
Disability
Marital Status
Political Beliefs
Ethnic Origin
Complainant’s Relationship to Wakulla County School Board (please check one):
Employee
Applicant
Visitor
Volunteer
Section II
Explanation of Event
(Please provide a thorough description of events including names of witnesses. You may use an
attachment if necessary):
___________________________________________________________________________________________________
Section III
Remedy Sought
___________________________________________________________________________________
I attest that the above information is true and correct to the best of my knowledge.
________________________________________
____________________________________
Complainant’s Signature
Date
WMIS HR2169 12/09, 12/10, 04/12
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