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
