Exhibit C — Employee Complaint — Level Two Appeal Notice
To appeal a Level One decision, or the lack of a timely response after a Level One conference, please fill out this form completely and submit it within the time established in DGBA(LOCAL). Appeals will be heard in accordance with DGBA(LEGAL) and (LOCAL) or any exceptions outlined therein.
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
Campus Department
*
Please Select
Fairfield High School
Fairfield Junior High
Fairfield Intermediate School
Fairfield Elementary School
Transportation
Maintenance
Food Services
Adminstration
If you will be represented in presenting your appeal, please identify the person representing you. If the person representing you will participate by telephone conference call, please mark below. The District will inform you if the equipment necessary for telephone representation is unavailable.
Yes, by telephone
Not by telephone
Please note:
You must designate a representative who will be participating in person or by telephone with an advance notice of at least three days, or the District may reschedule theconference or hearing to a later date.
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
Who held the Level One conference?
*
Date of conference:
*
-
Month
-
Day
Year
Date
Date you received a response to the Level One conference:
*
-
Month
-
Day
Year
Date
Please explain specifically how you disagree with the outcome at Level One.
*
Attach a copy of the Level One response being appealed, if applicable.
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Employee signature:
*
Signature of employee’s representative:
Date of filing:
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Continue
Continue
Should be Empty: