Grievance Report
Contact Information
Name
*
First Name
Last Name
Relationship to District (select one)
*
Employee
Parent/Guardian
Student
Community Member
Other (please specify below)
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Zip Code
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Employee
Campus or Department
*
Immediate Supervisor's Name
*
Have you already discussed this issue with your supervisor?
*
Yes
No
Would you like to request that this grievance begin at Level Two (Superintendent)because your supervisor is involved in the issue?
*
Yes
No
Are you represented by anyone in this matter?
*
Yes
No
What is your representative's name and contact information (phone, email, address)?
*
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Parent/Guardian or Student
Student's Name (if applicable
First Name
Last Name
Student's Grade (if applicable)
Please Select
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Campus
*
Elementary
High School
Day Nursery
Teacher or staff member involved (if applicable)
Have you spoken with the teacher or principal about this issue?
*
Yes
No
List the name of the person with whom you spoke and the date of the conversation.
*
Name / date
Do you wish to include your student in conferences related to this grievance?
*
Yes
No
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Community Member
Are you a current or former district employee?
*
Yes
No
Describe your connection to the issue or event.
*
Have you previously discussed this concern with a district administrator?
*
Yes
No
List the name of the person with whom you spoke and the date of the conversation.
*
Name / date
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Complaint Details
Date of the decision or action giving rise to the complaint
*
-
Month
-
Day
Year
Date
Date you first became aware of the issue (if different)
-
Month
-
Day
Year
Date
Please identify the individual(s), department(s), or campus involved.
*
Describe your concern or complaint in detail.
*
include what happened, when, and who was involved
What specific outcome or resolution are you seeking?
*
describe what you want the District to do
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Supporting Documentation
Do you wish to upload any supporting documents?
*
Yes
No
Upload files here:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Have you previously discussed this concern informally with a district employee?
*
Yes
No
Please provide the name, date, and a brief summary of the discussion.
*
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Certification and Acknowledgment
I understand that this complaint must be filed within 15 district business days of the date I knew or should have known of the issue.
*
I acknowledge and agree
I understand that submitting this form begins the formal grievance process under district policy.
*
I acknowledge and agree
Signature
Date submitted
*
-
Month
-
Day
Year
Date
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