Code No. 101.3E2 Grievance Form For Complaint of Discrimination or Non-Compliance with Federal or State Regulations Requiring Non-Discrimination

Grievance Form for Complaints of Discrimination or Non-Compliance with Federal or State Regulations Requiring Non-Discrimination

 

I,                                                                    , am filing this grievance because

 

 

 

 

 

 

 

 

 

(Attach additional sheets if necessary)

 

Describe incident or occurrence as accurately as possible:

 

 

 

 

 

 

 

 

 

 

 

 

 (Attach additional sheets if necessary)

 

Signature

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

If student, name

 

Grade Level

 

 

 

 

 

Attendance center

 

 

 
                     

 

 

 

 

 

 

Name of Individual Alleging Discrimination or Non-Compliance

Name

 

 

 

Grievance Date

 
     

State the nature of the complaint and the remedy requested.

 

 

 

 

 

 

 

 

 

Indicate Principal's or Supervisor's response or action to above complaint.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Principal or Supervisor

 
     

 

Approved:  October 22, 2012

Revised/Reviewed:  February 27, 2023