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Complaint Form
Complaint Procedure
Date
*
MM slash DD slash YYYY
Name
*
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
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Washington
West Virginia
Wisconsin
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Armed Forces Americas
Armed Forces Europe
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State
ZIP Code
Phone
Email
*
Please select your title
*
Community Member
Employee
Parent
Student
Current Building
*
Ankeny Centennial High School
Ankeny High School
Northview Middle School
Southview Middle School
Parkview Middle School
Prairie Ridge Middle School
Ashland Ridge Elementary
Crocker Elementary
East Elementary
Heritage Elementary
Northeast Elementary
Northwest Elementary
Prairie Trail Elementary
Rock Creek Elementary
Southeast Elementary
Westwood Elementary
Terrace Learning Center (Preschool)
District Office
Neveln
Other
Have you talked to the building principal or immediate supervisor to try to resolve the problem?
*
Yes
No
If the conduct involves your principal or immediate supervisor, have you followed the chain of command and contacted that person's immediate supervisor?
*
Yes
No
You are required to cooperate fully with any investigation conducted by Ankeny 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.
Do you understand the statement above?
*
Yes
No
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.
Do you understand the statement above?
*
Yes
No
Do you want to file a complaint?
*
Yes
No
Against who?
*
Do you need to add another person to your complaint?
*
Yes
No
Against Who? (2nd)
*
First
Last
The allegation is:
*
On what basis?
*
Discrimination
Bullying/Harrassment (Students Only)
Sexual Harrassment
Hostile Work Environment (Employee Only)
Section 504 Violation
Nature of discrimination, harassment, or bullying (check all that apply by holding down the ctrl or command key):
*
Age
Disability
Familial Status
Gender Identity
Marital Status
National Origin/Ethnic Background/Ancestry
Physical Attribute
Physical/Mental Ability
Political Belief
Political Party Preference
Race/Color
Religion/Creed
Sex
Sexual Orientation
Socio-economic Background
Other
District Policies:
102.00 Equal Educational Opportunity
401.01 Equal Employment Opportunity
402.13 Harassment 504.45
Inappropriate Student Interaction
What parts of the policy do you believe are being violated?
*
When did this alleged treatment begin?
*
MM slash DD slash YYYY
Type Full Name
*
Consent
*
I agree that the above statements are true.
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