Form Fm 5199 – Fill Out and Use This PDF

MIAMI-DADE COUNTY PUBLIC SCHOOLS

Office of Civil Rights Compliance

STUDENT/PARENT COMPLAINT FORM

NAME:_______________________________	STUDENT ID #:______________________
ADDRESS:___________________________	SCHOOL:___________________________
CITY/STATE/ZIP:______________________	WORK LOCATION:___________________
HOME PHONE:_______________________	WORK PHONE:______________________

Instructions: The purpose of this form is to assist you in presenting your complaint, in accordance with School Board guidelines. The information you provide on this form will allow staff in the Office of Civil Rights Compliance (CRC) to decide what questions to ask individuals who may have knowledge of the facts concerning your complaint.

It is requested that you provide as much detail as possible when completing the Student/Parent Complaint Form. Please attach any documents which you believe will support your complaint. If you need additional space, feel free to attach additional pages. All the information provided must be true and accurate.

1. What person(s) allegedly discriminated retaliated and/or harassed you?

2.As to each person who allegedly discriminated, retaliated and/or harassed you, please describe in detail, what occurred and specifically describe the exact event or action which you believe was discriminatory, retaliatory and/or harassing.

3.When did the alleged discrimination, retaliation and/or harassment occur? (Give an approximate date for the first time the alleged discrimination, retaliation and/or harassment occurred and, if there has been more that one act/episode.)

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4.How long and in what capacity have you known the person(s) who allegedly discriminated, harassed and/ or retaliated against you? (Example: “I have know Mr./Ms. X for 1 year. He/She is currently my teacher.”)

5.What school were you attending at the time of the alleged discrimination, retaliation and/or harassment?

6. What school are you attending now?

7.What action(s), if any, did you take after the alleged discrimination, retaliation, and/or harassment? (State as specific as possible, the dates of the action(s) taken.)

8.Did you report this to an administrator, teacher or worksite administrator? If yes, please give the name(s) of those individual(s) and if possible, provide a work location or phone number where they can be reached. State specifically what you said and the response(s) given and/or the action taken by the administrator.

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9.List the name(s) of other individuals who may have first-hand knowledge of the facts related to your complaint. If possible, please provide a work location or phone number where they may be reached.

Name	Contact Information
________________________________	_________________________________
________________________________	_________________________________
________________________________	_________________________________

10.Please check the applicable category upon which your complaint is based. It should be noted that the descriptions provided below are intended to assist you with understanding the varying categories and should not be considered “legal definitions.”

____ Age - this category prevents denial of equal employment and/or educational

opportunities and/or harassment because of a person’s age.

____ Color - this category prevents denial of equal employment and/or educational

opportunities and/or harassment because of a person’s skintone. Color discrimination can be a subclass within a race and is based on the fact that a person’s skin tone is different from their own. As such, color discrimination can occur within the same race. For example someone who is darker complexioned may discriminate against someone who has a lighter complexion although they are both members of the same race.

____ Disability - this category prevents denial of equal employment and/or educational

opportunities and/or harassment because a person either has or is perceived to have a permanent impairment that substantially limits or prevents a major life activity.

____ Ethnic or National Origin - this category prevents denial of equal employment

and/or educational opportunities and/or harassment because of a person’s or his/her ancestor’s, place of origin; or because an individual has the physical, cultural or linguistic characteristics of a national origin group.

____ Gender - this category prevents denial of equal employment and/or educational

opportunities and/or harassment because of a person’s gender or sex; it ensures that males are not treated differently from females and/or vice versa. Gender discrimination also includes sexual harassment and pregnancy discrimination which are explained below.

____ Linguistic Preference - a subclass of national origin discrimination, this category

prevents denial of equal employment and/or educational opportunities and/or harassment because of the language a person speaks unless there is a legitimate business need for requiring that a specific language be spoken.

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____ Marital Status - this category prevents denial of equal employment and/or

educational opportunities and/or harassment because a person is or is not married.

____ Political Beliefs - this category prevents denial of equal employment and/or

educational opportunities and/or harassment because of a person’s support and/or affiliation or lack thereof with a particular political party.

____ Pregnancy - this discrimination is a form of gender/sex discrimination, this

category prevents denial of equal employment and/or educational opportunities and/or harassment of women who are with child.

____ Race - this category prevents denial of equal employment and/or educational

opportunities and/or harassment because of a person’s race. The five recognized races are American Indian or Alaska Native, Asian, Black or African American; Hawaiian or Other Pacific Islander; and White. Because everyone has a race they can be discriminated against because of race. Persons from mixed racial backgrounds do not need to prove their exact heritage in order to assert that they have been discriminated against based on race. Likewise this category covers persons being discriminated against because they are married to persons of a different race from their own.

____ Religion - this category prevents denial of equal employment and/or educational

opportunities and/or harassment because of a person’s sincerely held religious practices. In certain circumstances it affords persons accommodations based upon their sincerely held religious practices.

____ Retaliation - this category prevents persons from taking an adverse employment

or educational action against any person that has opposed activity that violates a persons Civil Rights or participated in an investigation pertaining to Civil Rights where there is a link between the adverse employment action and the person’s opposition to Civil Rights violations or participation in a Civil Rights investigation.

____ Sexual Harassment - this category prevents unwelcome sexual advances;

requests for sexual favors; and other verbal or physical conduct of a sexual nature, when submission to such conduct is made – either explicitly or implicitly – a term or condition of employment or participation in an educational program; submission to or rejection of such conduct by an individual is used as the basis for employment or educational decisions affecting such individual; or such conduct has the purpose or effect of unreasonably interfering with an individual’s work or academic performance or creating an intimidating, hostile, or offensive working or educational environment.

____ Sexual Orientation - this category prevents denial of equal employment and/or

educational opportunities and/or harassment because of a person’s sexual preference, this is based on whether an individual is heterosexual, homosexual, or bi-sexual.

____ Social and Family Background - this category prevents denial of equal

employment and/or educational opportunities and/or harassment because of a person’s socio-economic, familiar and/or educational background.

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I understand that the information I have provided will determine the scope of CRC’s investigation of my complaint. I have read the above complaint and commit that the content provided is true and to the best of my knowledge, accurate. I understand that knowingly submitting false information may lead to disciplinary action(s) against me.

_____________________________	______________________________
Signature of Student	Signature of Parent
____________________________	______________________________
Printed Name of Student	Printed Name of Parent
____________________________	___________________________
Date	Date

(If the student is a minor, Parent/Guardian signature is required.)

(Please be sure to retain a copy of this form and all other supporting documents for your records.)

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Miami-Dade County Public Schools

Office of Civil Rights Compliance

PARENTAL AUTHORIZATION FOR STUDENT TO

BE INTERVIEWED

As part of the investigative process, the assigned investigator from the Office of Civil Rights Compliance (CRC) would like to interview your child. Therefore, this form is a request for your permission/authorization to interview your child regarding the following allegation_____________________________________________.

The interview will be conducted at the school site with two (2) adults present and your presence and attendance is encouraged as well. Please indicate your approval/disapproval to allow your child to participate in the interview process by checking the appropriate line below:

I do ____/do not ____ consent to my child being interviewed by a CRC

investigator.

I do ____/do not ____ wish to be present for my child’s interview with a CRC

investigator.

To ensure proper communication regarding this request and to coordinate your attendance at the interview, please provide a telephone number where you may be reached during normal business hours so that the assigned investigator may schedule your child’s interview at a time when you are available: ____________________

(phone number).

________________________________	__________________________________
Signature of Student	Signature of Parent
_______________________________	__________________________________
Printed Name of Student	Printed Name of Parent
_______________________________	__________________________________
Date	Date

(If the student is a minor, Parent/Guardian signature is required.)

(Please be sure to retain a copy of this form and all other supporting documents for your records.)

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