Student Title VI (Civil Rights) Incident Report Form

Student Title VI (Civil Rights) Incident Report

Office of Human Resurces
A form must be filled out for each student who is reporting a complaint (Complainant). In the case of a complaint against more than one person (Respondent), another form must be completed for each individual (Respondent).
1. Your Information
Your Full Name
Your email
Your role
If other, please describe

2. Complainant Information

Student Submitting the Complaint
Complainant Full Name
Complainant LASID
Complainant School
Caregiver Name
Caregiver Email
Caregiver Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred caregiver language
If other, please specify

3. Respondent Information

Student against whom the complaint is being made
Respondent Full Name
Respondent LASID
Respondent School
Caregiver Name
Caregiver email
Caregiver Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Caregiver Language
If other, please specify

4. Incident Report

Important: To protect the integrity of the investigation, please do not discuss this report with the alleged respondent. Contact the Civil Rights Coordinator first for guidance on next steps.
Please provide a detailed account of what happened. Since Civil Rights investigations are fact-based, include dates, times, specific locations, and the names of any individuals involved or witnesses present.
5. Support Measures for the Complainant
Indicate whether any support measures have been or will be provided to the Complainant. Note that support measures must be offered even if the Complainant does not file a formal complaint.

Examples include, but are not limited to: counseling, extensions of deadlines, course-related adjustments, schedule changes, mutual contact restrictions, campus escort, leaves of absence, or increased safety and monitoring.

Except in cases of emergency removal, support measures are not disciplinary. The District will keep these measures confidential unless disclosure is necessary to provide the support measures themselves.
List any specific support measures requested by the complainant, parent, or guardian:
After a conversation with the Complainant and consideration of their preferences, the following support measures were implemented:
If any requested support measures were denied, explain the reason below:
Support Documentation (If Any)

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Should be Empty:

Student Title VI (Civil Rights) Incident Report