GRIEVANCE FORM

GRIEVANCE FORM
GRIEVANT INFORMATION
NAME
Title(Student, Parent, Staff, etc)
BUILDING (IF APPLICABLE)
Contact Information (PHONE)
Format: (000) 000-0000.
Email
MAILING ADDRESS
DETAILS OF EVENT LEADING TO GRIEVANCE
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Location of Event
ACCOUNT OF EVENT: Provide a detailed account of the occurrence. Include the names of any additional persons involved.
Violations: Provide a list of any policies, procedures, or guidelines you believe have been violated in the event described.
Witnesses if applicable
Other information
PROPOSED SOLUTION
Please retain a copy of this form for your own records. As the grievant, your signature below indicates that the information you've provided on this form is truthful.
SIGNATURES
GRIEVANT SIGNATURE
DATE

MonthDayYear
Date
RECEIVED BY: PRINTED NAME AND SIGNATURE
DATE

MonthDayYear
Date
SJDA GRIEVANCE FORM (rev. 7/2024)
Should be Empty: