0110.1E Non-Discrimination and Anti-Harassment of Students Form

0110.1E

COMPLAINT FORM FOR STUDENTS REPORTING DISCRIMINATION AND/OR HARASSMENT 

If you believe you have been subjected to discrimination or harassment, you are encouraged to complete this form and submit it to one of the Civil Rights Compliance Officers of the ICHABOD CRANE CENTRAL SCHOOL DISTRICT. The Civil Rights Compliance Officer is Lucas Christensen. He can be reached at LChristensen@IchabodCrane.org or (518) 758-7575, ext. 3009. You will not be retaliated against for filing a complaint. 

If you are more comfortable reporting verbally or in another manner, a Compliance Officer may complete this form, provide you with a copy, and follow the District’s Anti-Discrimination and Anti-Harassment policies by investigating the claims as outlined in the District’s administrative regulations. 

COMPLAINANT INFORMATION 

Name: ______________________________ 

Address: ______________________________ Phone: _____________________ Email: ______________________________ 

Grade: ______________________________ 

Select Preferred Communication Method: ☐Email ☐Phone ☐In person 

COMPLAINT INFORMATION 

  1. Your complaint of discrimination or harassment is made about: 

Name: ______________________________ 

Title: ______________________________ 

Address: ______________________________ 

Phone: ______________________________ 

Relationship to you: ☐Student ☐Administrator ☐Teacher ☐Staff ☐Other

  1. Please describe what happened and how it is affecting you and your work. Please use additional sheets of paper if necessary and attach any relevant documents or evidence. 
  2. Date(s) harassment or discrimination occurred: _______________ 

Is the discrimination or harassment continuing? ☐Yes ☐No 

  1. Please list the name and contact information of any witnesses or individuals who may have information related to your complaint: 

The last question is optional, but may help the investigation. 

  1. Have you previously complained or provided information (verbal or written) about related incidents? If yes, when and to whom did you complain or provide information? 

Signature: __________________________ Date: __________________

Effective Date: March 5, 2024 (0110.1 Exhibit)