DISCRIMINATION GRIEVANCE COMPLAINT FORM

Name and Address of Charging Party (Grievant):

_____________________________________________________________________________________

_____________________________________________________________________________________

Date: ___________________________

Phone numbers where Grievant may be reached:

Home: __________________________ Office: _____________________________

Cell: ____________________________ Other: _____________________________

Statement of grievance (please provide as detailed a statement as is possible and attach additional pages so that we

may have a complete understanding of your concerns):

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Please identify any documents or other materials that support your grievance. If documents or materials are in your

possession, please attach copies to this grievance. If documents or materials are not in your possession, please indicate

where they are located.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Please identify what action or relief you are seeking as a result of this grievance.

_____________________________________________________________________________________

_____________________________________________________________________________________

_______________________________________

Signature of Grievant

Section 504/Title II Coordinator – Special Services Director (for questions or complaints based on disability

concerning students) and Section 504/Title II Coordinator - Personnel Director (for questions or complaints based on

disability concerning employees, patrons and other adults)

500 South New Bethel Blvd.

Ada, OK 74820

Telephone: 580-436-3020

Title VI (for questions or complaints based on race, color and national origin), Title IX (for questions or complaints

based on sex), and Age Act (for questions or complaints based on age)

Coordinator – Personnel Director

500 South New Bethel Blvd.

Ada, OK 74820

Telephone: 580-436-3020

If, as a result of a disability, you need assistance in completing this form, please contact the

District’s Section 504/Title II Coordinator – Special Services Director or Section 504/Title II Coordinator

- Personnel Director for assistance or accommodation.