Grievance Form for Complaints of Discrimination or Non-Compliance with Federal or State Regulations Requiring Non-Discrimination
I, , am filing this grievance because |
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(Attach additional sheets if necessary)
Describe incident or occurrence as accurately as possible:
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(Attach additional sheets if necessary)
Signature |
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Address |
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Phone Number |
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If student, name |
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Grade Level |
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Attendance center |
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Name of Individual Alleging Discrimination or Non-Compliance
Name |
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Grievance Date |
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State the nature of the complaint and the remedy requested.
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Indicate Principal's or Supervisor's response or action to above complaint.
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Signature of Principal or Supervisor |
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Approved: October 22, 2012
Revised/Reviewed: February 27, 2023