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

I,_____________________________________, am filing this grievance because

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

(attached additional sheets as necessary)

Describe incident or occurrence as accurately as possible:

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_________________________________________

REVIEWED: 11/18/2019 - APPROVED 12/03/2019
REVIEWED: 08/17/2020
REVISED: 02/08/2021 – APPROVED 03/15/2021

dawn.gibson.cm… Mon, 01/17/2022 - 14:56