Discrimination/Harassment UCP

Discrimination/Harassment Uniform Complaint Procedure

K-12 COMPLAINT FORM
To:

Uniform Complaint Officer

Brea Olinda Unified School District

1 Civic Center Circle, Level 2

Brea, California 92821

Phone: (714) 990-7800

Fax: (714) 529-2137
From:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Cell)*
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Other)
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Program(s) Concerned (Please check below)
Discrimination or harassment in programs receiving state financial assistance based on one of the following protected classes:

Race/EthnicityNationalityImmigration StatusMarital or Parental StatusSexual OrientationGender ExpressionColorNational OriginAgePhysical or Mental DisabilityGenderGenetic InformationAncestryEthnic Group IdentificationReligionSexGender IdentityOther
OR
A violation of federal or state law or regulation governing the following program(s):

After School Education/SafetyAmerican Indian Ed. CentersBilingual EducationCareer Technical/Tech Ed. TrainingChild Care and DevelopmentChild NutritionCompensatory EducationConsolidated Categorical AideCourse Periods w/o Ed. ContentEarly Childhood Education/AssessmentsEducation of: Foster; Homeless, Military; Juvenile Court School StudentsEnglish Learner ProgramsEvery Student Succeeds Act (Titles I – VII)LCAPMigrant EducationPeer Assistance and Review for TeachersPE Instructional MinutesPupil FeesReasonable Accommodations – Lactating PupilRegional Occupational CentersSchool Safety PlansSpecial EducationState PreschoolTobacco-Use Prevention Education
NATURE OF COMPLAINT:
This should be a description in your own words of the grounds of your complaint, including all names, dates, and places necessary for a complete understanding of your complaint. Attach additional sheets, if necessary.*
Have you spoken with any District staff regarding this complaint?*

YesNo
If so, what are their names?
What was the result of the discussion?
Date Submitted*

MonthDayYear
Date
Please provide a signature below. All complaints should be dated.*
Should be Empty:

Discrimination/Harassment Uniform Complaint Procedure

To:

From:

Program(s) Concerned (Please check below)

NATURE OF COMPLAINT: