434R-B - Appendix: School Nutrition Services Complaint of Harassment/Discrimination

  • Complete form and submit to Frederick County Public Schools’ Supervisor of School Nutrition Services within 180 days of the alleged discriminatory action.

    Supervisor of School Nutrition Services
    1415 Amherst St.
    Winchester, VA 22601
    540-662-3888

    Name of Complainant: ______________________________________________________

    Address: _________________________________________________________________________________________________________________________________

    Phone Number: ____________________________________________________________


    What happened to you? Please include date, location and any supporting documentation that would help show what happened.

    ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

     

    Who do you believe harassed/discriminated against you? List name(s).

    ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

     

    Name(s) of witness(es) to alleged prohibited conduct, if applicable.

    ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

     

    It is a violation of the law to harass/discriminate against you based on the following: race, color, national origin, religion, sex, disability, age, marital status, sexual orientation, family/parental status, income derived form a public assistance program, and political beliefs. I believe I was harassed/discriminated against based on my:

    ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

     

    How would you like to see this complaint resolved?

    ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


    In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

    Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.


    To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.

    This institution is an equal opportunity provider.

     

    Adopted: April 18, 2018
    Amended: August 15, 2018