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

Code No.  101.3E2
 
 
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
 
Reviewed: December 22, 2014