STUDENT DISCRIMINATION/HARASSMENT COMPLAINT FORM
TO: Superintendent, Acton School Dept. Date of Receipt by Superintendent: ____________________
700 Milton Mills Road
Acton, ME 04001
Type of dispute resolution requested (select one):
____ Mediation ____ Complaint
If requesting a complaint are you willing to participate in mediation? ___ Yes ___ No (A mediation will not interfere with the timelines for a complaint.)
Name: ____________________________________________________________________________
Address: __________________________________________________________________________
__________________________________________________________________________________
Telephone: Home: ________ - _________ Work: ________ - _________ FAX: _____ - _________
Student’s name if this is being made for a student.
Date of Birth: _______ / _______ / _______ Disability: _________________________________
(If Applicable)
Student’s Residence (if different from parent): ____________________________________________
School district the student attends: ______________________________________________________
School: ____________________________________________ Grade: __________________
Attorney/advocate: ___________________________________
Address: ___________________________________________
___________________________________________________
Telephone: (______) ______ - _______ FAX: (______) ______ - _______
Describe the nature of the problem and any facts relating to the problem. (Attach additional pages if necessary.)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Please complete page 2 of this request form.
STUDENT DISCRIMINATION/HARASSMENT COMPLAINT FORM (Continued)
How could this problem be resolved? (Attach additional pages if necessary.)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What actions has the school taken to address the problem?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Who did you notify? __________________________ Date notified: _______ / _______ / _______
How did you notify this person?
____________________________________________________________________________________
____________________________________________________________________________________
Signature of individual submitting request: __________________________ Date: ____ / ____ / ______
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For additional information or assistance, you may wish to contact:
The Superintendent or Affirmative Action Officer of Acton School Department – Tel: 636-2100, FAX: 636-3045
The Special Needs Parent Information Network (SPIN) – 1-800-870-7746
The Maine Human Rights Commission 624-6050.
Adopted: March 14, 2017