Public Grievance

Date Received

MonthDayYear
Date
Exhibit C: PUBLIC GRIEVANCE

GF (LEGAL) & (LOCAL)

LEVEL TWO

NOTICE OF APPEAL

This form must be filled out completely by a member of the public appealing a Level One decision to theSuperintendent or designee in accordance with the District’s policy GF (Legal) & (Local). To appeal aLevel One decision, please fill out this form completely and submit it by hand delivery, fax, e-mail or U.S.mail to the Superintendent or designee within the time established in GF (Local). Appeals must be filedwithin 20 days of receiving a written decision. Please be advised that the only remedies ruled upon shallbe those listed in the Level Two Grievance Form. Remedies requested in an oral manner at any hearinglevel shall not be considered. At the discretion of the hearing officer, you shall be afforded a reasonableamount of time to present your grievance.
Grievant's information (All information is required)
Name*
Address*
City/State*
Phone*
E-mail*
example@example.com
If you will be represented, please idenity 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
E-mail
example@example.com
Please answer the following questions:
1) To whom did you present your grievance at Level One?*
Date conference was held:*

MonthDayYear
Date
2) Date you received the written response to the Level One Conference:

MonthDayYear
Date
3) Why do you disagree with the Level One response? Please explain in detail. Specifically list the remedy or remedies requested, but not granted, at Level One.
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 Two 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)

Please answer the following questions: