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 relevant dates, times, and places.

_____________________________________________________________________

If there is anyone who could provide more information regarding this complaint, 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.