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Series 0000 - Mission-Goals-Objective

Form 0521-Discrimination Grievance Form
Posted 02/01/2013 11:00AM

0521 Form

Suffield, Connecticut

Discrimination Grievance Form

Any student, parent/guardian, employee or employment applicant who feels that he/she has been discriminated against on the basis of race, color, age, national origin, marital status, sex, sexual orientation, gender identity or expression, or disability may discuss and/or file a grievance with the Title IX Coordinator of the Suffield Public Schools. Reporting should take place 40 calendar days of the alleged discrimination. Title IX Coordinator:

Assistant Superintendent of Curriculum and Instruction
(860) 668-3806

Name of Presenter/Complainant:_________________________________

Employee ___ Employment Applicant ___ Student ___ Parent/Guardian___

Home address ________________________________________________

Phone ____________ Date of Claim _______ Date of Incident _________

  1. Statement of Incident/Issue (include all pertinent information: who, how, where, when, how often, feelings, witness).
  2. Please attach any additional information/documentation as necessary.

Signature of Presenter: _______________________________

Signature of Title IX Coordinator: _______________________

Date Received: _____________________________________

Forms are available from the Title IX Coordinator,
Administrators and Guidance Offices.

Download the PDF of this Form

Suffield Public Schools 350 Mountain Road, Suffield, CT 06078
Central Office Phone: 860-668-3800 | Central Office Fax: 860-668-3805 |   Site Map

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