Exhibit A — Employee Complaint Form — Level One
Note: Informal resolution is encouraged but does not extend any deadlines in DGBA(LOCAL), except by mutual written consent. Whistleblower complaints must be filed within the time specified by law and may be made to the Superintendent or designee beginning at Level Two. This form is required to initiate any employee 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 to the appropriate administrator within the time established in DGBA(LOCAL). All complaints 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 advance notice of at least three days, or the District may reschedule the conference 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
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 the person with whom you communicated 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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Employee signature:
*
Signature of employee’s representative:
Date of filing:
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
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