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The School District of Lee County

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Discrimination Complaint Form

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Discrimination Complaint Form

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Discrimination Complaint Form

Non-Discrimination Policy

Discrimination Complaint Form

Discrimination Information

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Discrimination Complaint (English)
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Discrimination Complaint Form

First Name:

Last Name:

Address:

City:

State:

Zip:

Phone Number:

Email:

What do you believe was the reason for the discriminatory or harassing treatment?

Race or Color
Religion
Disability
Sex / Orientation
National Origin
Age
Other

Check one that applies:

Student

School:

Grade:

Employee

School:

Job Position:

Have you filed this complaint with any other agency?

No
Yes (If yes, Name of agency and date filed)

Name of Agency:

Date Filed:

Were there any witnesses?

No
Yes

Explain the discriminatory or harassing act that occurred and all individuals involved. If the complaint involves a policy, explain how and why it discriminates. A short statement in your own words is sufficient.

By typing your Full Name in the signature field:
"I swear or affirm that I have read the above complaint and that it is true to the best of my knowledge and belief."

Date:

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If you are not contacted by the Office of Legal Services within 72 hours, please call (239) 337-8512.

The School District ofLee County

2855 Colonial Blvd, Fort Myers, FL 33966Phone: 239-334-1102TTD/TTY: 239-335-1512

Under Florida law, e-mail addresses are public records. If you do not want your email address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.

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