COMPLAINT FORM

Date __________________________

Name of Complainant _____________________________________________________________________________

Address of Complainant ___________________________________________________________________________
                                                    street                                                         city                                               zip

School __________________________________________________________________________________________

Assignment (if employee) ___________________________________________________________________________

Grade (if student) _________________________________________________________________________________

1. Date Cause of Complaint Occurred __________________________________

2. Statement of Complaint __________________________________________________________________________

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3. Identify Specific Provision of the Law or Regulations Violated __________________________________________

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4. Identify Specific Relief Sought ____________________________________________________________________

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                                        signature                                                                                                 date

 

Disposition by Responsible Official __________________________________________________________________

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                                        signature                                                                                                 date