Los Angeles Unified School District
UNIFORM COMPLAINT PROCEDURES FORM

Last Name ________________________ First Name _________________________ Street Address/Apt. # ___________________________________________________ City _____________________________ State ___________ Zip _______________ Home Phone ______________________ Message/Work Phone _________________

Please check the box that appropriately refers to your complaint: ___ Adult Basic Education ___ Consolidated Categorical Aid Programs ___ Migrant Education ___ Child Care and Developmental Programs ___ vocational Education ___ Child Nutrition Programs ___ Special Education Programs ___ Unlawful Discrimination (based on ethnicity, religion, age, (40 or above), gender, color, sexual orientation, physical or mental disability (including AIDS), medical condition (cancer related), marital status, ancestry, or political belief or affiliation)

Please explain the nature of your complaint. Please print or type. Give detailed information such as date, times, places, types of complaints, and if there were any witnesses. Use the reverse of this form or additional sheets if necessary.

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