Civil Rights Complaint Form
Civil Rights Complaint Form

Guilford Preparatory Academy

“Learning, Leading, Living”

Alton Woods Board Chair

Dr. Robin Buckrham Principal                                                                   

(Ref. – FNS Instruction 113)            

CIVIL RIGHTS COMPLAINT FORM

Guilford Preparatory Academy

Child Nutrition Program

 

School Food Authority: Guilford Preparatory Academy    

Date of the Incident: 

Name of person or persons accused of discrimination  

_________________________________________________________________________________________ 

Date of the Complaint: 

Complaint Filed by: 

 

Address City & Zip Code 

 

Home Phone  Cell Phone

 

Email address

 

Nature of complaint (include location, date, time, circumstances surrounding the alleged incident, description of what happened):

 

 

Names/signatures of witnesses:

   

Lynn Harvey, Section Chief                                                  U.S. Department of Agriculture           

Child Nutrition Services                                                          Food and Nutrition Service    

NC Department of Public Instruction                                     61 Forsyth Street, SW                       

6324 Mail Service Center                                                     Suite 3B70                             

301 N. Wilmington Street.                                                     Atlanta, GA  30303-8931       

Raleigh, NC  27699-6324                                                                                                                                      

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.



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