DEKALB COUNTY SCHOOL DISTRICT
1701 Mountain Industrial Boulevard
Stone Mountain, Georgia 30083-1027
PERSONNEL COMPLAINT FORM
This form is to be used to file Complaints in accordance with GAE(2), GAE(3) and GAEB, or for general stakeholder complaints
Please check applicable categories:
[ ] ADMINISTRATOR/SUPERVISORY POSITION [ ] CERTIFIED [ ] NON-CERTIFIED/CLASSIFIED EMPLOYEE
[ ] INFORMAL RESOLUTION CONFERENCE – Informal Early Intervention Discussion to resolve workplace disputes. This request
must be filed within ten (10) days after the date on which the cause giving rise to the Complaint is known.
[ ] LEVEL 1 / FORMAL COMPLAINT – Presentation of evidence in support of a Complaint, before a Hearing Officer who issues an
written decision based upon the evidence presented. This request must be filed within ten (10) days after the date on which the cause giving
rise to the Complaint is known.
[ ] LEVEL II APPEAL – Must be filed within ten (10) calendar days of the Level I Hearing Officer’s Decision.
[ ] LEVEL III APPEAL to the Board of Education – Must be filed within ten (10) calendar days of the Level II Hearing Officer’s
Decision. (Please Note: A Level III Appeal is not available to Classified personnel.)
[ ] UNPROFESSIONAL CONDUCT [ ] HARASSMENT [ ] HOSTILE WORK ENVIRONMENT [ ] BULLYING
[ ] SEXUAL HARASSMENT – Request for an investigation into allegations regarding inappropriate verbal and/or physical contact of a
sexual nature.
Employee’s Name _________________________________________ School or Department ___________________________________
Home Address _____________________________________________ City ______________________ State_________ Zip_________
Email Address ___________________________________________
Home Phone ___________________________Cellular Phone _______________________ Employee ID# _________________________
Date of Hire _______________________ Position/Classification __________________________________________________________
EMPLOYEE’S STATEMENT OF COMPLAINT
1. State the date of the occurrence of the most recent incident or other matter on which the Complaint is based: _________________
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2. Names(s) and title(s) of charged party or parties: _________________________________________________________________
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3. Names(s) of witness(es), if any:_______________________________________________________________________________
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4. What statute, policy, rule, regulation, or written agreement has been violated, misapplied, or misinterpreted? _________________
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5. Briefly describe the specific facts or events on which the Complaint is based. Explain how such statute, policy, rule, regulation, or
written agreement was violated, misapplied, or misinterpreted, and how it affects the employment relationship or the Complainant?
Please include names, dates, places, times and other specifics on attached page(s) if needed._______________________________
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6. How are you affected by the alleged violation of your employment?__________________________________________________
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7. What relief are you seeking? _________________________________________________________________________________
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I hereby present the following Complaint to the Office of Internal Affairs. I understand that this Complaint will be
reviewed and investigated in accordance with the Superintendent’s procedures and the adopted Board of Education’s
Complaint Resolution Policies.
______________________________________________________________ _____________________
Employee’s Signature Date
Revised and Issued 07/13/2011
Legal References
- O.C.G.A. 19-07-0005 — Reporting child abuse (Lexis)
- O.C.G.A. 20-02-1184 — Mandatory reporting of students committing certain prohibited acts (Lexis)
- 18 USC 1513 — Retaliating against a witness, victim, or an informant
- 20 USC 1681 — Title IX-Prohibition against discrimination based on sex
- 34 CFR 100.7 — Title VI - Conduct of investigations
- 34 CFR 104.7 — Section 504 - Designation of responsible employee and adoption of grievance procedures
- 34 CFR 106.30 — Definitions. (Title IX Sexual Harassment)
- 34 CFR 106.44 — Recipient's response to sexual harassment
- 34 CFR 106.45 — Grievance process for formal complaints of sexual harassment
- 34 CFR 106.8 — Title IX - Designation of coordinator, dissemination of policy, and adoption of grievance procedures
- 42 USC 2000d — Civil Rights Act-Prohibition against discrimination in federally assisted programs on basis of race, color, or national origin
- 42 USC 2000e-2 — Unlawful employment practices
- 45 CFR 86.57 — Discrimination based upon marital or parental status prohibited