Complaint Form

Date*

Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Email*

Please select your title*

Current Building*

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?*

Nature of discrimination, harassment, or bullying (check all that apply by holding down the ctrl or command key):*

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?*

Type Full Name*

Consent*

I agree that the above statements are true.

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Complaint Procedure