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104.2 Grievance Form for Complaints of Discrimination or Non-Compliance with Federal or State Regulations Requiring Non-Discrimination

GRIEVANCE FORM FOR COMPLAINTS OF DISCRIMINATION OR NON-COMPLIANCE WITH FEDERAL OR STATE REGULATIONS REQUIRING NON-DISCRIMINATION

 

I,                                                                                                                           , am filing this grievance because

 

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

(Attach additional sheets if necessary)

Describe incident or occurrence as accurately as possible:

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

                                                                                                                                                                                                                         

(Attach additional sheets if necessary)

Signature                                                                                                                                                                                                                                                                                           

Address

 

                                                                                                                                                  

                                                                                                                                                           

 

 

 

Phone Number                                                                                                     

 

 

 

If student, name                                                                                                                                 

 

Grade Level                

 

Attendance center                                                                                                                              

 

 

 
                     

 

Name of Individual Alleging Discrimination or Non-Compliance

Name

 

                                                                                                                                                                                                             

Grievance Date                                                                     

 
     

State the nature of the complaint and the remedy requested.

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

Indicate Principal's or Supervisor's response or action to above complaint.

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

                                                                                                                                                                                                                           

 

Signature of Principal or Supervisor