Discrimination Reporting Form (Title VI/VII) Complaint Form

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Discrimination Reporting Form (Title VI/VII) Complaint Form - Anti-discrimination)

Holt Public Schools is committed to a welcoming, safe environment. We are committed to protecting the rights of all of our stakeholders, including those outlined in Title VI and VII as anti-discrimination measures. Any stakeholder who would like to report a behavior that may violate Title VI/VII protections may use this digital form as the official report. They may be required to sign a copy of the form during the investigation.

Email *

Please describe the nature of the complaint. *

When did the actions described above occur? *

If there were witnesses, please list them.

If you have spoken with anyone about the incident, please list who and what you have shared, as well as the date.

Please describe the result of the discussions you have had about the incident.

What is your name? *

What is your role in the district? *

What is your home address? *

What is your phone number? *

What school do you attend? (if applicable)

What grade are you in? (if applicable)

By typing your name below, you certify that the information you shared is true and correct. *

A copy of your responses will be emailed to the address you provided.

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