Public Grievance

Date Received
Exhibit A: Public Grievance

GF (LEGAL) & (LOCAL)
Level One

Notice of Grievance to Administrator

Any member of the public filing a grievance must fill out this form completely and submit it by hand delivery, fax, e-mail or U.S. mail to the appropriate central administrator within the time established in GF (Local), which is 60 days from the date of the incident, 90 days from the date of the incident if an informal resolution is attempted, or 30 days from the receipt of filing instructions. All grievances will be processed in accordance with GF (Legal) and (Local).
Grievant's information (All information is required)
Name*
Address*

Street Address

Street Address Line 2

City, StateState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
E-mail*
example@example.com
If you will be represented, please identify the person representing you.
What is their role?

Legal CounselRepresentative
Name/Organization
Address

Street Address

Street Address Line 2

City, StateState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
E-mail
example@example.com
Please complete the following questions:
1) Please describe the decision or circumstances causing your grievance (give specific details, continue on separate paper if necessary).*
2) What was the date of the decision or circumstance causing your grievance?*

MonthDayYear
Date
3a) How you have been harmed by this decision or circumstance:*
3b) The District policy violated, misinterpreted, or misapplied:*
4) What efforts have you made to resolve your grievance informally and the response to your efforts?*
5) With whom did you communicate?*
6) On what date?*

MonthDayYear
Date
7) Please describe the outcome or remedy you seek for this grievance.*
8) If you are making grievances or charges against any specific individuals, please identify each of those individuals by name and title:
9) Are you alleging a violation of the Texas Whistleblower Act?*

YesNo
10) Are you alleging a violation of law? If so, please identify below:*
11) Are you alleging that your supervisor either violated the law in the workplace or has unlawfully harassed you?*

YesNo
Grievant, please note:

A grievance form that is incomplete in any material may be dismissed, but may be re-filed with all the required information if the re-filing is within the designated time for filing a grievance. Attach to this form any documents you believe will support the grievance. Please keep a copy of the completed form and any supporting documentation for your records. If established by policy, a review or appeal of a grievance must be conducted by a person with the authority to address the grievance unless a preliminary hearing is necessary to develop a record or a recommendation for the board of trustees of the school district. Please be advised that a grievant is allowed to add claims or documents during the grievance process. However, the grievance may be remanded to a lower level in order to develop the record, if necessary. Please be advised that the only remedies ruled upon shall be those listed in the Level One Grievance Form. Remedies requested in an oral manner at any hearing level shall not be considered. At the discretion of the hearing officer, you shall be afforded a reasonable amount of time to present your grievance.
Grievant Signature*

Clear
Print Name*
Date of Filing*
Signature of Grievant's representative

Clear
Print Name
Date
Superintendent's signature/Designee

Clear
Print Name
Date Received
Should be Empty:

Grievant's information (All information is required)

If you will be represented, please identify the person representing you.

Please complete the following questions: