AC-E-2, Nondiscrimination/Equal Opportunity Complaint Form
While the text of Board Exhibit AC-E-2, Nondiscrimination/Equal Opportunity Complaint Form, is below, one can submit the TSD Complaint Form online.
AC-E-2, Nondiscrimination/Equal Opportunity Complaint Form
In compliance with Titles VI and VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination in Employment Act of 1967, the Americans with Disabilities Act, the Genetic Information Nondiscrimination Act of 2008, and Colorado law, the Thompson School District does not unlawfully discriminate against otherwise qualified students, employees, applicants for employment, or members of the public on the basis of disability, race, creed, color, sex, sexual orientation, gender identity, gender expression, marital status, national origin, religion, ancestry, family composition, or need for special education services. Discrimination against employees and applicants for employment based on age, genetic information, and conditions related to pregnancy or childbirth is also prohibited in accordance with state and/or federal law. Harassment, if it rises to the level described in state law, is a prohibited form of discrimination.
If you believe that you or someone you know has been the target of discrimination (including harassment) or retaliation, please complete this form, sign where indicated below, and submit it by hand delivery, electronic mail, or U.S. mail to the compliance officer as directed below.
The following person(s) have been identified as the compliance officer for the district:
Title IX Coordinator, ADA and Section 504 Coordinator, and EEO Compliance Officer, for all matters and complaints involving employees and nonemployees (i.e. members of the public).
Valerie Lara-Black, Department of Human Resources
800 South Taft Avenue
Loveland, Colorado 80537
(970) 613-5009
Valerie.Lara-Black@tsd.org
Title IX Coordinator, ADA and Section 504 Coordinator, and Non-Discrimination Compliance Officer for all matters and complaints involving students only.:
Colin Dike, Department of Student Support Services
800 South Taft Avenue
Loveland, Colorado 80537
(970) 613-5092
Colin.Dike@tsd.org
Reporter Information
Date: _______________
Name of person making the complaint: _________________________________________
Person making the complaint is:
❑ Student ❑ Parent ❑ Grandparent ❑ Guardian ❑ School Staff
❑ Other (please specify): _________________________________________________
Contact information of person reporting:
School: ________________________________________________________
Address: ________________________________________________________
Phone: _________________ Email: __________________________
Are you the target (complainant) of the alleged discrimination, harassment, or retaliation? ❑ Yes ❑ No
If you are the complainant, are you asking that your identity be kept confidential as a supportive measure? ❑ Yes ❑ No
If you are not the complainant, does the complainant require confidentiality?
❑ Yes ❑ No
❑ Please check here for allegations of sex-based discrimination and/or sexual harassment. (Note: Investigator will use investigation procedures consistent with allegations of sex-based discrimination and/or sexual harassment).
Details of Persons Involved in Incident(s)
Person(s) believed to be target(s) of alleged discrimination, harassment, or retaliation (please attach additional sheets/information as needed):
Name: _____________________________________________________________________
☐ Student, School of Attendance: ________________________; Grade: ______
☐ Staff
☐ Other: ____________________________________________________
Name: _____________________________________________________________________
☐ Student, School of Attendance: ________________________; Grade: ______
☐ Staff
☐ Other: ____________________________________________________
Person(s) believed to be engaged in alleged discrimination, harassment, or retaliation:
Name: ____________________________________________________
☐ Student, School of Attendance: ________________________; Grade: ______
☐ Staff
☐ Other: ____________________________________________________
Name: ____________________________________________________
☐ Student, School of Attendance: ________________________; Grade: ______
☐ Staff
☐ Other: ____________________________________________________
Incident Details
Date(s) of the incident(s) allegedly involving discrimination, harassment, or retaliation:
Time(s)/time(s) of day:
Location(s) of incident(s):
Please provide a description of the incident(s) and any supporting documentation. (Please be specific and provide factual details. Use additional pages, if needed. Also, include any relevant background information and correspondence between the parties.):
Witness(es) Information
Are there any witnesses to the incident(s)? ❑ Yes ❑ No
May the school staff investigating this complaint contact these witnesses? ❑ Yes ❑ No
If so, please provide the names and contact information.
Witness Name: ____________________________________________________
☐ Student, School of Attendance: ________________________; Grade: ______
☐ Staff
☐ Other: ____________________________________________________
Witness Name: ____________________________________________________
☐ Student, School of Attendance: ________________________; Grade: ______
☐ Staff
☐ Other: ____________________________________________________
Requested Resolution/Corrective Action
Your suggestions regarding resolving the complaint:
Please describe any corrective action you wish to see taken with regard to the alleged discrimination or harassment. You may also provide other information relevant to this complaint.
By completing and signing this form, I attest that the information provided, including any attached incident-related information, is true and accurate to the best of my knowledge.
Signature
Date
For Office Use Only:
Signature of person receiving complaint
Date
Revised November 14, 2012
Revised July 29, 2020
Revised January 17, 2024
Revised November 19, 2025