JICEC-E ©

EXHIBIT

FREEDOM OF EXPRESSION

COMPLAINT FORM

(To be filed with the school principal)
Additional pages may be attached if more space is needed.

Please print:

Name ____________________________________ Date ______________

Address _______________________________________________________

Telephone _________ Another phone where you can be reached _________

During the hours of ______________________________________________

E-mail address __________________________________________________

I wish to complain against:

Name of person, school (department), program, or activity _______________

______________________________________________________________

Address _______________________________________________________

Specify your complaint by stating the problem as you see it. Describe the incident, the participants, the background to the incident, and any attempts you have made to solve the problem. Be sure to note relevant dates, times, and places.

______________________________________________________________

If there is anyone who could provide more information regarding this, please list name(s), address(es), and telephone number(s).

Name Address Telephone Number

______________________________________________________________

The projected solution

Indicate what you think can and should be done to solve the problem. Be as specific as possible.

______________________________________________________________

I certify that this information is correct to the best of my knowledge.

__________________________________ _________________________
Signature of Complainant Date Signed

__________________________________ _________________________
Principal receiving the initial complaint Date initial complaint received

The principal shall give one (1) copy to the complainant and retain one (1) copy for the file.