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: August 23, 2016
Revised/Reviewed: February 27, 2023