The availability and use of this internal procedure via submission of a complaint form does not preclude filing a complaint of discrimination with any
appropriate state or federal agency. Revised October 2012
7387 S Campus View Drive West Jordan, UT 84084
Phone: (801) 567-8150 Fax: (801) 567-8056
C
OMPLAINT OF
A
LLEGED
D
ISCRIMINATION
To be filed with the Human Resources Department. Upon
completion and submission of this form, the District Compliance
Officer will initiate an internal investigation of alleged discrimination.
Complainant Name: Date:
Home Address: Contact Phone #:
City, State, Zip: E-mail:
Applicant Employee Patron Student Other
I. Provision of Jordan School District policy or state/federal law allegedly being violated, misinterpreted, or
misapplied (cite policy or statute number, if known):
II. Cause of alleged discrimination (Check all that apply)
Race National Origin Gender Religion Marital Status
Age Disability Military Status Other
III. Statement of complaint (attach additional pages, if needed).
Please include location(s), date(s), names of individuals
involved, and why you believe Jordan School District policy or state/federal law was violated, misinterpreted, or misapplied:
IV. Relief or action requested to resolve complaint:
Signature: Date:
District Office Use
Date complaint submitted to Compliance Officer:
Action taken by Compliance Officer:
Was complaint filed with the Board of Education? Yes No If yes, date filed:
