Stakeholder Grievance Form

Today's Daterequired

Must contain a date in M/D/YYYY format

Namerequired

First Name

Last Name

Email Addressrequired

Phone Numberrequired

If Relationship is "Other," please specify.

See above.

If grievance involves a student matter, please provide the name of student:

Select at least one location.

If Location is "Other," please specify.

See above.

Provide a description of your grievance or concern, including dates:*required

If your grievance relates to a School Board or school policy or regulation, please specify the policy, regulation or procedure:

Describe the resolution you are seeking:*required

In regards to steps I have already taken to resolve my concern, I have talked/met with the teacher/my supervisor:*required

Yes

No

If you have spoken to the teacher / supervisor, please provide his/her name and date of conversation.

Basis for claim and relief sought - explain your dispute with the response from the teacher or your supervisor:

Do you dispute the policy?

Yes

No

Do you dispute the facts?

Yes

No

Do you dispute how the policy was applied with the facts?

Yes

No

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