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Ruotolo  \nSuperintendent of Schools Interim Director, Human Resources  \nStamford Public Schools Concerns/Complaint Form  \nInstructions:  \nBefore completing this form please read all instructions, including the Release Statement on page 6.  \nPlease print all responses.  \nINDIVIDUAL FILING COMPLAINT:  \nName:  \n__________________________________________________________________________________  \nMailing address:   Phone number, home:   Phone number, work:    \nRelationship to Stamford Public Schools (parent, teacher,student, etc. )    \nIf employee, please complete the following information  \nCurrent job title:   Department:   Work location:   How long have you worked for Stamford Public Schools?    \n  Yes   No  \nHave you attempted to resolve this matter by discussing it with someone else (administration, management, union, EAP)?  \nIf YES, please provide details:    \n____________________________________________________________________________________  \n_________________________________________________________________________________________  \nName:    \nTitle:  \n____________________________________________________________________________________  \nDepartment:   Work location:   GENERAL NATURE OF COMPLAINT: (please check all applicable boxes and provide dates on lines provided)  \n_________________________________________________________________________________________  \n_________________________________________________________________________________________  \nDate or timeframe the problem occurred:  \non or about   If you feel that you have been subject to discrimination, please complete the following:  \nI believe I have been discriminated against based on one or more of the following:  \n☐ Race ☐ Age (over 40)  \n☐ Sex ☐ Color  \n☐ National Origin ☐ Religion/Creed  \n☐ Sexual Orientation ☐ Physical Disability  \n☐ Mental Disability/Disorder ☐ Learning Disability  \n☐ Marital Status ☐ Prior Criminal Record  \n☐ Other:   Have you filed an official complaint with any other agency or commenced a private legal investigation?  \n  Yes   No  \nIf YES, with whom was the action commenced?   At what stage is this action?    \nDo you know of additional school community members, employees or applicants of this group (basis of discrimination above) who were treated the same way you allege you or the subject of this complaint were? If yes, provide names, titles, race, sex, etc., and explain.  \n  Yes   No  \n_________________________________________________________________________________________  \n_________________________________________________________________________________________  \n1. Describe in detail the alleged act(s) indicating dates, places, names and titles of persons involved. Provide sufficient details to assist in investigations. Add additional pages if necessary.  \n_________________________________________________________________________________________  \n_________________________________________________________________________________________  \n_________________________________________________________________________________________  \n_________________________________________________________________________________________  \n_________________________________________________________________________________________  \n_________________________________________________________________________________________  \n_________________________________________________________________________________________  \n_________________________________________________________________________________________  \n_________________________________________________________________________________________  \n_________________________________________________________________________________________  \n_____________________","cbCaighlMyGo81k9","https://ap.wps.com/l/cbCaighlMyGo81k9","pdf",199404,"English","# Instructions\n# Individual Filing Complaint\n## Personal and Employment Details\n## Attempted Resolution and Details\n## If Employee, Job Information\n## General Nature of Complaint\n## Discrimination Basis and Other Agency Filings\n## Additional Affected Individuals\n# Narrative Questions\n## Describe Alleged Acts\n## Respondent Explanation\n## Witness Information\n# Outcome of the Investigation\n# Confidentiality Statement","[{\"question\":\"How should the complaint be submitted and filled out?\",\"answer\":\"Read the instructions, including the release statement on page 6, and print all responses. Provide the requested details in each section and include signature and date submitted at the end.\"},{\"question\":\"What information is required for a discrimination claim?\",\"answer\":\"Indicate whether you believe discrimination occurred and select the applicable basis categories. Provide additional details such as other individuals treated similarly if applicable.\"},{\"question\":\"What does the form ask for in the alleged acts section and the investigation outcome?\",\"answer\":\"Describe the alleged acts in detail, including dates, places, and the names and titles of involved persons, and add pages if needed. Also state the resolution you want as the outcome of the investigation.\"}]","Stamford Public Schools Concerns/Complaint Form | PDF",1789851876]