Complaint Form - REAL Journey Academies

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First some information from you* This field is required.Your name:
First Name
Last Name
2
Your Email* This field is required.Email address we can contact you:
example@example.com
3
AddressMailing address for documentation if applicable:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
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United States
Afghanistan
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Other
Country
4
Primary Phone Number* This field is required.Best phone number to reach you at:
Please enter a valid phone number.
5
You are filing this complaint on behalf of:* This field is required.
Myself
A parent/guardian
A pupil
A witness to the incident
Other
6
Complainant Name (if applicable)Name of person you are submitting complaint for:
First Name
Last Name
7
Primary Contact Number* This field is required.Best number to reach the person you are submitting this complaint for:
Please enter a valid phone number.
8
School Site* This field is required.Provide the school site name:
iEmpire Academy (K-5th in San Bernardino)
Journey School (K-6th in Moreno Valley)
New Vision Middle (6th-8th in Highland)
Entrepreneur High (9th - 12th in Highland)
Entrepreneur High Fontana (9th - 12th in Fontana)
9
Has this complaint been previously reported to any staff members?* This field is required.Please inform us if this complaint has been previously reported to any school site staff members?
YESNO
10
Basis of Complaint* This field is required.Type of complaint you want to report (check those that apply):
Special Education
Title II - Lunch Program Complaint
Title IX - Discrimination
Section 504 of the Rehabilitation Act
Child Care & Development Program Complaint
Child Nutrition Program
Career and Technical Education Program
Local Control Accountability Plan Complaint
Consolidated Categorical Aid
Migrant Education
Other/Unknown
11
Unlawful Discrimination Details* This field is required.Unlawful discrimination, including discriminatory harassment, intimidation, or bullying, based on actual or perceived characteristics of the following
Age
Ancestry
Color
Physical or Mental Disability
Ethnic Group Identification
Gender Expression
Gender Identity
Gender
Genetic Information
Marital or Parental Status
Sex
Sexual Orientation
Race
National Origin
Religion
Sexual Harassments (Title IX)
Association with any of these actual or perceived characteristics
Other/Unknown
12
Is there allegations of noncompliance of the following:* This field is required.Retaliation against an already made complaint or other participant in the complain process or anyone who has acted to uncover or report a violation subject to the complaint procedure?
Yes
No
I don't know for certain
13
Details of ComplaintPlease provide as much details as you can including names of staff/student/parents, school site, dates and times.
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List the individuals directly involved in the incident(s) complaint:Names if available, if not, please let us know their title (example: Principal, Vice Principal, Office staff, after school prgoram staff, campus aide, lunch staff, etc.)
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15
List any witnesses to the incident(s):
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What steps, if any, have you taken to resolve this issue before filing a complaint?
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17
Is there any other information you would like to provide?
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