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GRIEVANCE REPORT

 

FORM A

 

Step #1

 

                  FROM:                                                                                                                                                , Name of Grievant

 

                  BUILDING AND ASSIGNMENT:                                                                                                                                  

 

                  Date cause of grievance occurred:                                                                                                                                  

 

                  School district policy alleged to have been violated:                                                                                                   

 

                  Statement of grievant's claim (statement of facts upon which grievance is based, use additional pages if necessary):

                                                                                                                                                                                                                 

 

                                                                                                                                                                                                                 

 

                  Relief Desired:                                                                                                                                                                     

 

 

 

                                                                                                                                          _______________________________

                                                                                                                                          Signature

 

                                                                                                                                          _______________________________

                                                                                                                                          Date

 

***************************************************************************************************

 

Step #2    (To be used by Grievance Officer Only)

 

                  GRIEVANCE #_______________________________________________________________________

                                                          (to be assigned only if forwarded)

 

                  DATE FORWARDED: _________________________________________________________________

 

                  RESPONSE TO GRIEVANCE:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

 

                                                                                                                                          _______________________________

                                                                                                                                          Signature of Grievance Officer

 

                                                                                                                                          _______________________________

                                                                                                                                          Date

GRIEVANCE REPORT (Cont.)

 

 

APPEAL

FORM B

 

 

Step #3                                                                                                                            GRIEVANCE #___________________

                                                                                                                                          (assigned by grievance officer)

 

                          FROM:_________________________________________________________________________

                                                                                          Grieving Person

 

                          TO: ____________________________________________________________________________

                                                                                Superintendent or District Officer

 

                          SUBJ: __________________________________________________________________________

                                                                                      *Type of Grievance

 

                          DATE: _________________________________________________________________________

 

                                    * The Grievance Report (Form A) must be attached.

 

 

                                                                                                                                          _______________________________

                                                                                                                                          Signature

 

***************************************************************************************************

 

Step #4

 

                          DATE APPEAL RECEIVED _________________________________________________________

 

                          DATE OF RESPONSE TO APPEAL ____________________________________________________

 

                          RESPONSE TO APPEAL:

 

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

 

                                                                                                                                          _______________________________

                                                                                                                                          Signature of Supt. or District Officer

 

                                                                                                                                          _______________________________

                                                                                                                                          Date

 

 

GRIEVANCE REPORT (Cont.)

 

 

FORM C

 

 

Step #5                                                                                                                            Grievance # ______________________

 

                          FROM:                                                                                                                                       , Grieving Person

 

                          TO: __________________THE BOARD OF EDUCATION     _______________________________

 

                          SUBJ: __________________________________________________________________________

 

                          DATE: _________________________________________________________________________

 

                                                          *  Attach - Grievance Report (Form A)

 

                                                              Appeal           (Form B)

 

 

 

                                                                                                                                          _______________________________

                                                                                                                                          Signature

 

***************************************************************************************************

 

Step #6

 

                          DATE SECOND APPEAL RECEIVED _________________________________________________

 

                          DATE OF RESPONSE TO SECOND APPEAL ____________________________________________

 

                          RESPONSE TO SECOND APPEAL:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

 

 

                                                                                                                                    __________________________________

                                                                                                                                    Signature of President, Board of Education

 

                                                                                                                                    __________________________________

                                                                                                                                    Date

 

SUBMIT THIS FORM IN TRIPLICATE - ORIGINAL AND TWO CARBON COPIES.