West Valley School District Complaint Form

4220F
Complaint Form

COMPLAINT AGAINST A DISTRICT EMPLOYEE


To: Dr. Mike Brophy, Superintendent Date: ____________________

Name of employee(s) against whom
complaint is made: ___________________________________________________

Description of complaint (please include names, dates, places; use additional sheet if needed):

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Have you discussed
the complaint with: Employee? Yes No Name: Date: ________

Principal? Yes No Name: Date:________

Supervisor? Yes No Name: Date:               
Result of discussion(s): ________________________________________________________________________
                                                                                                                             
                                                                                                                             

How would complainant like this issue resolved? ___________________________________________________                                     
                                                                                                                             
                                                                                                                             

I the complainant understand that:

The School District may request further information about this complaint, and if such information is available, I shall present it upon request.

A copy of this complaint will be given by the School District to the employee against whom this complaint is being made, and he/she will be given the opportunity to respond in writing to this complaint and that I will receive from the School District a copy of such response.

 If a hearing is held on this complaint, it will be held in executive session with press and public excluded, and I will be informed of the time, date and place such hearing will be held.


Name of Complainant: __________________________________ Telephone #:_____________

Address: _____________________________________________________________________

Signature of Complainant: _____________________________________________________