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):
-----------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------
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: _____________________________________________________