Appeal Request Form

Custom Form

Toledo Public Schools
Appeal Request Form


Date: 

Case No: 

The dismissal of a formal complaint or allegations contained therein, or of the findings of responsibility on non-responsibility in the Final Determination Report, may be appealed by either the Complainant or the Respondent by submitting a request to the District's Title IX Coordinator using this form within seven (7) calendar days of the written Notice of Dismissal or issuance of the Final Determination Report. 

I , the Complainant or Respondent (check one) in this matter request an appeal of:
 the dismissal of my formal complaint or allegations therein; or
the findings of responsibility or non-responsibility made on the Final Determination Report. 

This request for appeal is based on the following grounds (select all that apply and provide a detailed explanation, attaching additional pages if necessary):
Procedural Irregularities affected the outcome of the matter, including dismissal of a complaint. Please explain:

Newly discovered evidence that could affect the outcome of the matter. Please explain: 

A conflict of interest or bias affected the outcome of the matter. Please explain:

Your request for appeal will be reviewed and forwarded to an Appellate Decision-Maker for further action. 

You may submit this form in person via fax, email or U.S. Mail to the District's Title IX Coordinator at the Office of Civil Rights Compliance using the contact information below:

Title IX Coordinator

Dr. Amerah Archer
Director of Equity, Diversity and Inclusion
417-671-0881
[email protected]

https://www.tps.org

Signature of Complainant or Respondent:
Printed Name: 
Date: 

Signature of Parent (if applicable):
Printed Name: 
Date: 

 



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