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Urbandale will be a school district that brings learning to life for everyone.
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Discrimination, Anti-Bullying, and Anti-Harassment Complaints
Complaint Form
(Discrimination, Anti-Bullying, and Anti-Harassment)
"
*
" indicates required fields
Date of Complaint
*
MM slash DD slash YYYY
Name of Complainant
*
First
Last
Home Address of Complainant
*
Street Address
Address Line 2
City
ZIP Code
Phone Number of Complainant
*
Your Email Address
*
Email Address
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Preferred Method of Contact
Email
Phone
Please select your role
*
Community Member
Employee
Parent
Student
Are you filling out this form for yourself?
*
Yes
No
(Please identify the individual if you are submitting on behalf of someone else)
Building where complaint should be directed (select from dropdown)
*
Karen Acres Elementary
Olmsted Elementary
Valerius Elementary
Webster Elementary
Urbandale Middle School
Urbandale High School
Metro West Learning Academy
District Office/Other
Athletics/Activities
Adventuretime
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 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.
*
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.
I understand the statement above.
*
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.
*
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.
I understand the statement above.
*
Complaint
Please provide as much detail as possible in this section.
Who or what entity do you believe discriminated against, harassed, or bullied you (or someone else)?
*
Name of any witnesses (if any):
Allegation
*
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.
File
Max. file size: 64 MB.
On what basis?
*
Discrimination
Bullying/Harassment (Students Only)
Sexual Harassment
Hostile Work Environment (Employees Only)
Nature of discrimination, harassment, or bullying alleged
*
(check all that apply)
Age
Disability
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Marital Status
National Origin/Ethnic Background/Ancestry
Physical Attribute
Physical/Mental Ability
Political Belief
Political Party Preference
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Sex
Sexual Orientation
Socio-economic Background
Other –please specify
If you indicated "other" above, please specify here.
When did the alleged treatment begin?
*
Type Your Full Name
*
Consent
*
I agree that the above statements are true to the best of my knowledge.
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