You are here

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

Code No. 103.2

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