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204.11 Exhibit A – Complaint Form

Code No. 204.11
Exhibit A
Page 1 of 3





Date Filed:                                                                                           

Name of Complainant:                                                                         

Telephone Number:                                                                              



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