JII-EA ©

EXHIBIT

STUDENT  CONCERNS,  COMPLAINTS,
AND  GRIEVANCES

COMPLAINT FORM

(To be filed with a school administrator or the administrator's immediate supervisor,
or a school staff member who will forward this form to the school administrator or
the administrator's immediate supervisor)
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 all 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

______________________________________     _____________________
Administrator or professional staff member                                Date initial complaint received
receiving initial complaint

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