0110.2E
COMPLAINT FORM FOR EMPLOYEES 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: ______________________________
Job Title (if applicable): ______________________________
Select Preferred Communication Method: ☐Email ☐Phone ☐In person
SUPERVISORY INFORMATION (if applicable)
Immediate Supervisor’s Name: ______________________________
Title: ______________________________
COMPLAINT INFORMATION
- Your complaint of discrimination or harassment is made about:
Name: ______________________________
Title: ______________________________
Work Address: ______________________________
Work Phone: ______________________________
Relationship to you: ☐Supervisor ☐Subordinate ☐Co-Worker ☐Teacher ☐Other Effective Date: March 5, 2024 (policy 0110.2)
- 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.
- Date(s) harassment or discrimination occurred: _______________
Is the discrimination or harassment continuing? ☐Yes ☐No
- 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.
- 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?
If you have retained legal counsel and would like us to work with them, please provide their contact information.
Signature: __________________________ Date: __________________
Effective Date: March 5, 2024 (policy 0110.2)