Exhibit A — Public Complaint Form — Level One
Informal resolution is encouraged but does not extend any deadlines in GF(LOCAL), except by mutual written consent. Please use this form to file a formal, initial complaint in accordance with GF(LOCAL), regardless of the level of administrator or hearing that may be designated by the District to respond to the complaint. This form is required to initiate any public complaint, regardless of the level at which the complaint begins. A complaint form that is incomplete in any material way may be refiled with the District upon completion 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, documents may be presented no later than the Level One conference unless you did not know the documents existed before the Level One conference. Please keep a copy of the completed form and any supporting documentation for your records.
To file a formal complaint, please fill out this form completely and submit it within the time established in GF(LOCAL). All complaints will be heard in accordance with GF(LEGAL) and (LOCAL) or any exceptions outlined therein. A person filing a complaint regarding refusal of entry to or ejection from property under the District’s control based on Education Code 37.105 will be permitted to address the Board in person within 90 calendar days of filing the initial complaint, unless the complaint is resolved before reaching the Board. [See GKA]
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
If you will be represented in presenting your complaint, please identify the person representing you.
Represented by- Name
First Name
Last Name
Represented by- Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Represented by- Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Represented by- Email
example@example.com
Please describe the decision or circumstances causing your complaint (give specific factual details).
*
What was the date of the decision or circumstances causing your complaint?
*
-
Month
-
Day
Year
Date
Please explain how you have been harmed by this decision or circumstance.
*
Please describe any efforts you have made to resolve your concerns and the responses to your efforts. Please include dates of communication and whom you communicated with regarding your concerns.
*
Please describe the outcome or remedy you seek for this complaint.
*
Attach to this form any documents you believe will support the complaint; if unavailable when you submit this form, documents may be presented no later than the Level One conference unless you did not know the documents existed before the Level One conference. Please keep a copy of the completed form and any supporting documentation for your records.
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FISD Superintendent
Fairfield High School Principal
Fairfield Junior High Principal
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Fairfield Elementary Principal
Complainant’s signature:
*
Signature of complainant’s representative:
Date of filing:
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