Code No. 102E2
GRIEVANCE FORM FOR COMPLAINTS OF DISCRIMINATION OR NON-COMPLIANCE
WITH FEDERAL OR STATE REGULATIONS REQUIRING NON-DISCRIMINATION
I, _________________________am filing this grievance because ________________________________
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(Attach additional sheets if necessary)
Describe incident or occurrence as accurately as possible: ______________________________________
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(Attach additional sheets if necessary)
Signature: __________________________________________________Date: _____________________
Address: _____________________________________________________________________________
Phone Number: ______________________
If student, name: ____________________________________________ Grade Level: _______________
Attendance center: _____________________________________________________________________
Assisting Staff member’s signature (if applicable): ____________________________________________
All complaints will be taken seriously and followed up with a written response to the person who has completed this form. Following the completion of the response the person completing this form will receive a copy and this will be entered into the district’s file in the event that it needs to be referenced at a later date. If the person who completes this form is not satisfied with the response, they should contact the District Superintendent at 641-236-2700.
Approved: 02/26/14
Reviewed:
Revised: 04/14/2021