104.2 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

 

 

 

 

 

First Reading Approved  2/12/2018                                      Second Reading Approved 3/12/2018