STUDENT/PARENT COMPLAINT FORM LEVEL ONE

STUDENT/PARENT COMPLAINT FORM LEVEL ONE
Parent Name

First NameLast Name
Student Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
TELEPHONE NUMBER
Format: (000) 000-0000.
Email
example@example.com
Campus
1. IF YOU WILL BE REPRESENTED IN PRESENTING YOUR COMPLAINT, PLEASE IDENTIFY THE PERSON REPRESENTING YOU.
ADDRESS
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
2. PLEASE DESCRIBE THE DECISION OR CIRCUMSTANCES CAUSING YOUR COMPLAINT- PLEASE GIVE SPECIFIC FACTUAL DETAILS.
3. WHAT WAS THE DATE OF THE DECISION OR CIRCUMSTANCES CAUSING YOUR COMPLAINT?

MonthDayYear
Date
4. PLEASE EXPLAIN HOW YOU OR YOUR CHILD MAY HAVE BEEN HARMED BY THIS DECISION OR CIRCUMSTANCE.
5. PLEASE DESCRIBE ANY EFFORTS YOU HAVE MADE TO RESOLVE YOUR COMPLAINT INFORMALLY AND THE RESPONSES TO YOUR EFFORTS.
6. WITH WHOM DID YOU COMMUNICATE?
7. ON WHAT DATE?

MonthDayYear
Date
8. PLEASE DESCRIBE THE OUTCOME OR REMEDY YOU SEEK FOR THIS COMPLAINT.
SIGNATURE OF COMPLAINANT
Date

MonthDayYear
Date
COMPLAINANT, PLEASE NOTE:
A complaint form that is incomplete in any material way may be dismissed but may be refiled with all the required information if the refiling is within the designated time for filing a complaint. Attach to this form any documents you believe will support the complaint; if unavailable when you submit this form, they may be presented no later than the Level One conference. Please keep a copy of the completed form and any supporting documentation for your records.
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STUDENT/PARENT COMPLAINT FORM LEVEL ONE

COMPLAINANT, PLEASE NOTE: