WSS DASA Complaint

Relationship to Districtrequired

Employee

Student

Parent or Guardian

Employment Applicant

Namerequired

First Name

Last Name

Please provide Job Titlerequired

Please provide student’s Full Namerequired

Home Addressrequired

Primary Phone Numberrequired

Alternate Phone Number

Work Phone Number

E-mail Address

Please specify.required

Name(s)/Title(s) of person(s) you believe discriminated against yourequired

Where did it take place (Please provide site name & addressrequired

Date on which alleged act(s) of discrimination occurredrequired

Must contain a date in M/D/YYYY format

Explain what happenedrequired

Names of all witnesses or others with substantial knowledge of the alleged incidents/harassment

The names of all persons with whom you have discussed the incidents/harassment which is the subject of this complain

Has the incident/harassment been previously reported?required

Yes

No

When and to whom?required

Describe the outcome of the previous reportrequired

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