Complaint Form

Discrimination, Anti-Bullying, and Anti-Harassment Complaint Form

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Name of Complainant*
Home Address of Complainant*
Your Email Address*
Are you filling out this form for yourself?*
Have you talked to the building principal or immediate supervisor to try to resolve the problem?*
If the conduct involves your principal or immediate supervisor, have you followed the chain of command and contacted that person's immediate supervisor?*
You are required to cooperate fully with any investigation conducted by Urbandale Community School District. You may not knowingly file a false complaint. If you knowingly provide untruthful or inaccurate statements, you may subject yourself to disciplinary action, up to and including termination.*
Retaliation against any person, because the person has filed a complaint or assisted or participated in an investigation, is prohibited. Persons found to have engaged in retaliation shall be subject to discipline by appropriate measures.*

Complaint

Please provide as much detail as possible in this section.
In the space below please describe what happened and why you believe that you or someone else has been discriminated against, harassed, or bullied. Please be as specific as possible, including listing actions you took to respond to the incidents. Attach any pertinent documents or additional pages if necessary.
Max. file size: 20 MB.
Consent*