Code No. 204.11
Exhibit A
Page 1 of 3
COMPLAINT FORM
DECORAH COMMUNITY SCHOOL DISTRICT
Date Filed:
Name of Complainant:
Telephone Number:
Address:
Statement of Complaint (include specific statement of incident(s), dates, persons involved, witnesses, and any other pertinent facts):
Remedy Sought:
Date you held informal meeting with employee involved:
Signature of Complainant Date
Code No. 204.11
Exhibit A
Page 2 of 3
Date Received by District employee:
Response by employee:
Signature of Employee Date
I wish to have this reconsidered by the employee's supervisor.
Signature of Complainant Date
Date Received by Supervisor
Date of Conference with Supervisor
Response by Supervisor:
Signature of Supervisor Date
I wish to have this reconsidered by the Superintendent or his/her designee.
Signature of Complainant Date
Code No. 204.11
Exhibit A
Page 3 of 3
Date Filed with Superintendent
Date of Conference with Superintendent
Response by Superintendent:
Signature of Superintendent Date
I wish to have this matter placed on the Board agenda:
Signature of Complainant Date
Dated Received by Board Secretary:
Placed on Board Agenda for:
Date Time