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GRIEVANCE FORM 

FOR COMPLAINTS OF DISCRIMINATION OR NON-COMPLIANCE WITH FEDERAL OR STATE REGULATIONS REQUIRING NON-DISCRIMINATION

Name of Grievant:

School:

Place where you can be reached:

Address:

Phone Number:

Summarize the nature of the grievance:

Attach additional sheets if necessary.

Please describe the remedy requested involving this alleged incident/occurrence:

Attach additional sheets if necessary.

Signature:

Date:

Received by:

Date: