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
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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
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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.
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