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2. 1. Name of the person filing this complaint:
4. First Name:
5. Middle Name:
6. Last Name:
8. Address
10. City
11. State
12. Zip Code
14. Home Telephone:
16. Work Telephone:
18. E-mail Address:
22. 2. Name of person discriminated against (if other than person filing). If the person discriminated against is age 18 or older, we will need that person's signature on this complaint form and the consent / release form before we can proceed with this complaint. If the person is a minor, and you do not have the legal authority to file a complaint on the student's behalf, the signature of the child's parent or legal guardian is required.
24. First Name:
25. Middle Name:
26. Last Name:
28. Address
30. City
31. State
32. Zip Code
34. Home Telephone:
36. Work Telephone:
38. E-mail Address:
42. 3. Government entity which you believe has discriminated:
44. Name:
46. Address
48. City
49. State
50. Zip Code
54. 4. The regulations DCTS enforces prohibit discrimination on the basis of race, color, national origin, sex, disability, age or retaliation. Please indicate the basis of your complaint:
56. Discrimination based on race (specify):
58. Discrimation based on color (specify):
60. Discrimination based on national origin (specify):
62. Discrimination based on sex (specify):
64. Discrimination based on disability (specify):
66. Discrimination based on age (specify):
68. Retaliation because you filed a complaint or asserted your rights (specify):
70. Complaint other than anything not listed above (specify):
74. 5. Please describe each alleged discriminatory act. For each action, please include the date(s) the discriminatory act occurred, the name(s) of each person(s) involved and, why you believe the discrimination was because of race, disability, age, sex, etc. Also please provide the names of any person(s) who was present and witnessed the act(s) of discrimination.
78. 6. What is the most recent date you were discriminated against?
    Date:
82. 7. If this date is more than 180 days ago, you may request a waiver of the filing requirement. I am requesting a waiver of the 180-day time frame for filing this complaint. Please explain why you waited until now to file your complaint.

    1. Yes
    2. No
84. If you answered yes, please describe the allegations in your grievance or hearing, identify the date you filed it, and tell us the status. If possible, please provide us with a copy of your grievance or appeal or due process request and, if completed, the decision in the matter.
88. 9. If the allegations contained in this complaint have been filed with any other Federal, state or local civil rights agency, or any Federal or state court, please give details and dates. We will determine whether it is appropriate to investigate your complaint based upon the specific allegations of your complaint and the actions taken by the other agency or court.
90. Agency or Court:
92. Date Filed:
94. Case Number or Reference:
96. Results of Investigation/Findings by Agency or Court:
100. 10. If we cannot reach you at your home or work, we would like to have the name and telephone number of another person (relative or friend) who knows where and when we can reach you. This information is not required, but it will be helpful to us.
102. First Name:
103. Middle Name:
104. Last Name:
106. Home Telephone:
108. Work Telephone:
112. 11. What would you like the institution to do as a result of your complaint - what remedy are you seeking?
116. 12. By submitting this form, you are confirming the information provided is true to the best of your knowledge and you are giving us authorization to investigate your claim.
Leave This Blank:


118. 1. Receive an email copy of this form.
119. Email address

     This field is not part of the form submission.

120. Submit

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