STUDENT HANDBOOK 2019-2020
10700 S. Palo Verde Road
P.O. Box 108
Palo Verde, AZ 85343
TABLE OF CONTENTS
July 29-August 5 Teacher In-Service
August 1 Meet the Teacher Night 6:00 P.M.
August 6 First Day of School, 2:00 release
August 21 School Pictures
August 26 Teachers In-Service
September 6 Progress Reports Home
October 4 End of First Quarter
October 10-11 Parent/Teacher Conferences, 2:00 release
October 11 Report Cards Home
October 25 School Picture Retakes
October 28 Teacher In-Service
November 8 Progress Reports Home
November 25-29 No School — Fall Break
December 20 End of Second Quarter
December 23–January 3 No School — Winter Break
January 10 Report Cards Home
January 27 Teacher In-Service
February 7 Progress Reports Home
March 5 Picture Retakes
March 6 End of Third Quarter
March 9-13 No School — Spring Break
March 20 Parent/Teacher Conferences, 2:00 release
March 20 Report Cards Home
March 23 Teacher In-Service
April 10 No School — Spring Holiday
April 17 Progress Reports Home
May 21 Eighth Grade Graduation 6:00 P.M.
May 22 Last Day of School, 11:30 release
EVERY MONDAY THROUGHOUT THE ENTIRE YEAR THERE WILL BE NO SCHOOL FOR STUDENTS.
This parent-student handbook has been prepared to provide essential information to the students and parents of Palo Verde School. Please take a few minutes to review the contents together.
The administration and staff would like to take this opportunity to welcome you to Palo Verde School. The information in this handbook has been compiled to help you succeed at Palo Verde School. The entire staff is here to assist you with your education. Come and share our positive attitude and vision of excellence.
"SCHOOLS ARE FOR CHILDREN”
"SCHOOLS BELONG TO THE COMMUNITY"
"SCHOOLS ARE PEOPLE DEVELOPERS"
The mission of the District is to provide comprehensive, success-oriented learning activities for young people in our schools.
These opportunities must be designed to develop the person's potential in the areas of academic ability and vocational awareness, cultural appreciation, physical well-being, social development, and community contribution.
It is the school’s responsibility to provide an environment, which motivates students to develop academically, physically, and socially, developing values, attitudes and skills required to function successfully in life and occupation. Students share with their parents and the school the responsibility for creating a positive school atmosphere. We believe that the primary purpose of the school is to provide a strong academic foundation for each student within a safe, secure environment.
The superintendent of the school determines that matters of school policy are in conformance with school district policy, and helps the teachers and parents understand the aims and purposes of the school. This administrator makes available to the teacher necessary materials and assists teachers in developing the instructional program.
When you have any question in regard to the operation of the school or any question about your child and his/her program of activities, you should contact the teacher, principal or superintendent.
It is the vision of the Palo Verde School District to design and promote a quality, effective school focused on the precept that all students can learn.
● Every student will be educated academically and socially so as to be a productive citizen.
● All students will have equal educational opportunities to achieve their individual potential.
● We have something to offer every student.
● Each student is unique.
● Successful education depends on parental commitment to education.
Palo Verde School will design and implement school programs, which will encourage students to:
Each student’s instructional program shall include but not necessarily be limited to fine arts, comprehensive health education, mathematics, language arts, science and social studies.
A Palo Verde School Curriculum Guide has been developed and outlines the scope and sequence of concepts and skills K-8 for all curriculum areas. The guide provides a complete perspective of the educational program, which clearly defines instructional sequence, continuity between levels and areas of curriculum responsibility.
Palo Verde School has aligned the Arizona State Academic Standards for each grade level, K-8. The purpose of the Academic Standards is to ensure the K-8 continuity of state required curriculum skills and expectations. Upon satisfactory completion of grade level standards requirements, program objectives and attainment of competencies at the level determined appropriate by the district, a student will be prepared to move into the next higher grade.
Instructional programs designed to meet the needs of students who require intervention instruction will be provided where needed. Criteria for determining a student’s eligibility for an intervention program has been developed by the Palo Verde School District’s professional staff.
When it becomes evident that a child has some exceptionality that is not permitting maximum performance in the regular class, it becomes necessary to evaluate the child’s program, and if at all possible, provide a program which aids in the fullest development of the child’s potential. For this reason, Special Education exists in Palo Verde School. Every child has the right to an education suitable to abilities and needs.
Gifted services are provided under the guidance of the Gifted Coordinator. Students will be assessed to determine areas of giftedness, and an extension program is provided for these students in the regular classroom environment.
Textbooks and electronic equipment will be furnished to your child. Each child is responsible for the proper care and return of the books and equipment. A fine will be charged for the loss, destruction or misuse of any items. Palo Verde School will supply some needed school supplies.
Our school maintains a library for student use. If a student checks out books or equipment, the responsibility for the proper care and return of the items. A student will be charged the replacement or repair of school property..
Two very important elements of the education process are good attitude and good behavior in the classroom and assigned homework being completed and turned in when due. To encourage the students in these areas, Palo Verde School has established MANDATORY After School Study Hall/Detention for students who are referred or that DO NOT turn in homework assignments. After School Study Hall/Detention is held on most Tuesdays, Wednesdays and Thursdays from 3:45 until approximately 4:55. Students are to record homework assignments in their agendas. Parents are encouraged to stay abreast of assignments due and the progress of their child. By looking at the planner each evening parents can determine what homework is due on the next school day.
The After School Study Hall/Detention is part of the regular educational program at Palo Verde School. THIS IS NOT AN OPTION NOR IS THERE A CHOICE INVOLVED. Students WILL remain after school if referred there or if homework is NOT turned in. The school recognizes that, on occasion, emergencies do occur and a student may be unable to remain for study hall/detention. In these cases, the student will be expected to make up the missed study hall/detention or an additional consequence will be applied.
The staff appreciates the cooperation of parents in our quest to provide a quality education for the students.
A District-developed grading system will be utilized, appropriate to the grade level and curriculum. Teachers will keep a careful record of the grades assigned to students. Written reports to the parents concerning student achievement will be made every nine weeks by the teacher, and additional written reports will be made when necessary. Additionally, teachers will confer with parents when necessary concerning academic progress and discipline of students. Teachers will report to parents on students’ conduct, scholarship, attendance or excessive tardiness. Parents will be given a login ID for the ParentVue program where they can review their child’s information and grades. Grades will be uploaded on a weekly basis to ParentVue.
Grades from grade 6, 7 and 3 quarters of grade 8 are the determining factor used to choose the Valedictorian and Salutatorian. Discipline records will be considered to be determining factors where needed.
Recommendations of 7th and 8th grade students for NJHS must portray the following attributes: scholarship, leadership, service, character, and citizenship. For each year of eligibility, the attributes will be displayed for the first three grading periods of the school year, maintaining an 85% or higher in each graded class.
It is important that the parent or guardian be kept informed of their child’s progress in school. The professional staff will make every effort to contact the home in order to report progress or to seek assistance when a learning problem is recognized or unresolved. The professional staff will schedule parent conferences as often as is necessary to achieve optimum understanding between the home and the school. Conferences are held regularly each year for all students K-8. Parents are also invited to schedule conferences with school personnel in an effort to promote home/school communications.
Pupils will receive report cards following the end of each nine-week period. Mid-nine week reports of failing or unsatisfactory work will be sent to parents. Unsatisfactory work may mean a pupil is not working to capacity or is in danger of failing if the quality of work is not improved. A failing notice means that a pupil is not doing work of sufficient nature to justify credit at the time the report is sent. Students must maintain a passing grade in all graded subjects in order to participate in any extra-curricular activity. A student who is ineligible for extra-curricular activities may not practice for that activity until the grade or grades meet criteria. Assessments will be taken each week during the year.
Grades 1st, 2nd, 3rd
Grades 4th, 5th
Grades 6th, 7th, 8th
These times may vary according to individual student work habits and the teacher’s judgment of student capabilities.
Since mastery of the fundamental skills is necessary for success at each succeeding grade level, the first consideration should be given to the mastery of these skills in considering a pupil for promotion, advancement or retention.
The regular school attendance of a child of school age is required by state law. Regular school attendance is essential for success in school; therefore, absences shall be excused only for necessary and important reasons. Such reasons include illness, bereavement, other family emergencies, and observance of major religious holidays of the family's faith.
In the event of a necessary absence known in advance, the parent is expected to inform the school; if the absence is caused by an emergency, such as illness, the parent is expected to telephone the school office.
State law mandates that the school record reasons for all student absences. Therefore, when a student is absent, it will be necessary for the parent to call the school on or before the day of absence in order to advise the school as to the reason for the absence. When it is impossible to call on the day of the absence, the school should be notified on the morning the student returns, in time for the student to obtain an admission slip prior to the student's first class. All absences not verified by parental or administrative authorization will remain unexcused.
If a parent does not have access to a phone, either at home or at work, a note will be accepted for verification purposes.
For absences greater than one (1) day in length, the school should be notified each day of the absence.
All personnel will solicit cooperation from parents in the matter of school attendance and punctuality, particularly in regard to the following:
● The scheduling of medical and dental appointments after school hours except in cases of emergency.
● The scheduling of family vacations during school vacation and recess periods.
The school may require an appointment card or a letter from a hospital or clinic when the parent has not notified the school of an appointment of a medical or dental nature.
School administrators are authorized to excuse students from school for necessary and justifiable reasons.
Throughout the school year, parents take students out of school for an extended period of time because of scheduled vacations, family emergencies and other extenuating circumstances.
The school is obligated to inform the parent of the following:
Truant means an unexcused absence for at least one (1) class period during the day. This includes absence from any class, study hall, or activity during the school day for which the student is scheduled.
Unexcused absence for at least five (5) school days within a school year constitutes habitual truancy. The Superintendent will establish procedures to identify and deal with unexcused absences, beginning with notification of parents. Continued violation may lead to discipline of the child and/or referral of the parent to a court of competent jurisdiction.
Many students strive for perfect attendance throughout the school year. To achieve perfect attendance a student must have zero excused and unexcused absences throughout the school year.
Birth certificates are required for students enrolling for the first time in Palo Verde School. If a birth certificate cannot be presented, a passport or Baptismal record is acceptable. If neither of these is available, the parent has thirty days to provide a certified copy of the birth certificate.
A student applying for admission to grades two through eight will be placed on the basis of prior schooling. The District will determine, subsequently, whether there should be any change in the grade placement of the student.
It is the responsibility of the parent or guardian to notify the school office at least five days prior to the withdrawal date. A student who leaves or withdraws prior to the last ten days of school will be considered as transfer status with no promotion, advancement or retention indicated on the report card or permanent record. A student who withdraws within the last ten (10) school days before the second semester ends will be promoted, advanced, or retained but should expect a reduction in grade. In all cases of early withdrawal, teachers will not provide advance assign
Our school maintains a cafeteria. The cafeteria must meet minimum standards as to quantities and qualities of food served. It must meet standards of cleanliness, and must provide a healthful meal served in pleasant surroundings. The school encourages the purchase of meals by the week or month. Children’s meal charges are discouraged by the Child Nutrition Program office, the United States Department of Agriculture, and the state Auditor General. A student can charge up to three (3) meals. After the three (3) meal limit, until such a time as all charges are paid, the student will be served a peanut butter and jelly sandwich. Meal money will be collected before school and during the morning recess. Students will pay for meals in the cafeteria.
Adults and Guests
Extra milk: $0.30
Parents have the primary responsibility for the health of their children. All children are expected to come to school clean at all times, adequately rested and to be in optimum good health. At school, the principal, teachers, office personnel, as well as others, are concerned for the protection and the health and safety of your child. Parents are asked to be especially careful in completing the health record that is kept at school. Children who are or have been infected with any communicable disease will be excluded from school and gatherings of children during the prescribed period of recovery.
No child can really enjoy his school when he is not physically up to par. Furthermore, the child may spread communicable disease among the other children. Please keep your child at home when he/she has the following symptoms:
Under certain circumstances, when it is necessary for a student to take medicine during school hours, the District will cooperate with the family physician and the parents if the following requirements are met:
The District reserves the right, in accordance with procedures established by the Superintendent, to circumscribe or disallow the use or administration of any medication on school premises if the threat of abuse or misuse of the medicine may pose a risk of harm to a member or members of the student population.
Immunization Regulations - It is unlawful for any student to be enrolled in school unless he or she has been immunized and can provide satisfactory evidence of such immunization. Students already enrolled who have turned in records previously need only to produce evidence of boosters taken throughout the year. The following immunizations are required:
Palo Verde maintains a complete permanent record for each student who is currently enrolled. Records include: grades, attendance, health, results of standardized achievement tests and intelligence, aptitude, interest test, or inventories.
Transcripts, grade reports and all other information within reasonable limitations will be released and/or reviewed with parents or guardians.
A request for a transcript or other academic information from another institution of learning will be honored as a matter of inter-institutional courtesy. There is no need to secure prior approval from the student and/or parent or guardian.
Requests from research organizations making statistical studies may be honored without prior approval provided no personally identifying information about the student is supplied.
Students are eligible for school transportation if the walking distance to school is at least 1.0 mile. Exceptions may be made if hazardous walking conditions exist or if a student is handicapped.
Students who come to school by bus are considered to be on campus while in route to and from school. Upon arrival at school, no student may leave the campus without permission of school authorities.
Buses must operate on rigid schedules therefore, it is imperative that students be prompt in boarding and leaving their bus.
Transportation of students is a privilege extended to students in the District.
Students will not be permitted to leave the bus on the way to and from school except at their regularly assigned stop.
Drivers shall not transport any person who is not enrolled in the Palo Verde School District without the express permission of the Superintendent.
Drivers shall not transport any student who is not a regular bus student to and from school.
Exceptions may be considered by the Director of Facilities/Transportation. The criteria for exceptions would be determined by State bus regulation.
The Pledge of Allegiance shall be recited daily by students. Students will have the right to refrain from participation in these activities due to sectarian, denominational or conscientious views; however, the exercise of this right may not interfere with the rights of others.
A student may be subject to disciplinary action when the student:
Reasonableness of use of physical force in self-defense, defense of others, and defense of property will be considered as a mitigating factor in determining penalties for misconduct. The threat or use of physical force by a student is not reasonable when:
The ranges of penalties that may be imposed for violations of student discipline rules may include but are not limited to, the following:
Depending upon the nature of the violation, student discipline shall be progressive, i.e., generally, a student’s first violation should merit a lighter penalty than subsequent violations. A district employee or agent should take into account all other relevant factors in determining an appropriate penalty. The above penalties may be imposed either alone or in combination.
Reasonable detention during and after school hours is permitted, provided that appropriate consideration is given to student transportation, weather, and other extenuating circumstances. If a student is unable to attend an after-school detention, they will serve 3 lunch detentions in the discipline room. If a student is given an after-school detention or the equivalent of 3 lunch detentions, they will not be allowed to participate in any after school activities that day.
The authority to suspend a student for up to ten days after an informal hearing is held rests with the Superintendent or designee. If a clear and present danger to students or staff is present, the Superintendent may immediately remove the student from school, with a notice and hearing following as soon as practicable. Each suspension shall be reported within five days to the Governing Board by the person imposing it.
In all cases, except summary suspension where a clear and present danger is evident, the student shall remain in school until applicable due-process procedures are instituted. Students will not be released early from school unless parents have been notified.
A recommendation to suspend for over 10 days or expel shall be the Superintendent’s. The authority to suspend for over 10 days or expel rests only with the Board. All expulsions requested shall have supporting data indicating the due-process procedure followed, the alternatives attempted, and the various District and approved agency resources used by the teachers, superintendent, support staff and parents to help the student adjust to the school environment.
The Superintendent is directed to establish procedures whereby students may present a complaint or grievance regarding a violation of their constitutional rights, equal access to programs, discrimination, harassment, intimidation, bullying or personal safety. For more information, please see Board Policy JII on the district website or get a copy in the school office.
The use or possession of intoxicants on school property or at school events is prohibited.
Any student in violation of the provision of the above paragraph shall be subject to removal from school property and shall be subject to prosecution in accordance with the provisions of the law.
When it is evident that a student has consumed alcoholic beverages off school property and/or before a school activity, he will not be allowed to be on school property or to participate in school activities. Students who violate this policy will be subject to the same penalties as for possession and/or consumption on school property. Students attending school in the District who are in violation of the provisions of this policy shall be subject to disciplinary actions in accordance with the provisions of school regulations.
Each student is expected to take pride in the physical appearance of the school. Teachers and students should be observant at all times to prevent damage or destruction of school property. Any marking or marring of school property should be reported to the Administration at once.
No student shall damage or deface any property belonging to the District. The District may institute formal charges for the purpose of having the court order the minor, or his/her parent/guardian, to make full or partial restitution to the District in accordance with law.
No student shall knowingly, intentionally, or recklessly go onto the school premises with a firearm, explosive weapon, knife, simulated weapon, or any other dangerous or illegal instrument, unless pursuant to written regulations or written authorization of the District. No student shall interfere with normal activities, occupancy, or use of any building or portion of the campus by exhibiting, using, or threatening to exhibit or use a firearm, explosive weapon, knife, simulated weapon, or other dangerous or illegal instrument. Any student violating this policy may be suspended or expelled.
There shall be no hazing or bullying of any student in attendance at the school. Hazing and bullying are defined as any act that injures, degrades, or disgraces, or tends to injure, degrade, or disgrace, any student. For complete definitions, please see Board Policy JICK on the district website or get a copy in the school office.
Any student or students being hazed or bullied should immediately complete the Student Complaint Form found in the handbook or school office and submit the form to their teacher or the school office.
In order to protect students and staff from the safety hazards of smoking and from an environment noxious to nonsmokers, and because the Board cannot condone the use of tobacco by students, the Board prohibits the possession, smoking, or use of tobacco by students:
The penalty for possession and/or use of tobacco or similar products will be determined by the Superintendent. Such penalties may include suspension from school.
A student may be recommended for expulsion from school when there is evidence of repeated and continuous disregard of regulations and policies of the school related to possession and use of tobacco or similar products.
A student shall be defined as any person who is regularly enrolled in good standing in an education program provided by or approved by the District and carried on in premises owned or controlled by the District.
Students in school buildings, on school grounds, using District property for any purpose, or attending a District-sanctioned event shall not engage in:
In addition to the general rules set forth above, students shall be expected to obey all policies and regulations for student conduct adopted by the Board. Students shall not engage in any activities prohibited herein, nor shall they refuse to obey any order given by a member of the faculty or staff who is attempting to maintain public order.
Any student who violates these policies and regulations may be subject to warning, reprimand, probation, suspension, or expulsion, in addition to other civil and criminal prosecution. These punishments may be in addition to any customary discipline that the District presently dispenses.
The Board requires students to conduct themselves in the bus, prior to boarding the bus, and subsequent to leaving the bus in a manner consistent with established standards for classroom behavior.
When a student does not conduct himself properly, the bus driver will inform the Director of Business Services and the Superintendent, of the misconduct. The student’s conduct may then be brought to the attention of the parents, resulting in suspension of riding privileges.
Students who become serious disciplinary problems related to school transportation will have their riding privileges suspended. In such cases, the parents of the student involved become responsible for seeing that their children get to and from school safely.
Students riding on special-activity buses are under the direct supervision of the bus driver in cooperation with sponsor(s). Students who do not conduct themselves properly will be denied the privilege of riding on special-activity buses.
The staff will implement the policy and regulation regarding student dress and appearance. The safety dress code as prescribed shall be followed. Footwear must be worn at all times.
The Board recognizes that each student’s mode of dress and grooming is a manifestation of personal style and individual preference. The Board will not interfere with the right of students and their parents to make decisions regarding their appearance except when their choices affect the educational program of the schools or the health and safety of others.
The Board authorizes the Superintendent to develop and enforce school regulations prohibiting student dress or grooming practices that:
Unacceptable items include, but are not limited to, the following:
If dress is deemed inappropriate or distracting to the learning environment, students will be asked to change.
The non-medical use, possession, or sale of drugs on school property or at school events is prohibited. Non-medical is defined as “a purpose other than the prevention, treatment, or cure of an illness or disabling condition”.
Students in violation of the provisions of the above paragraph shall be subject to removal from school property and shall be subject to prosecution in accordance with the provisions of the law.
Students attending school in the District who are in violation of the provisions of this policy shall be subject to disciplinary actions in accordance with the provisions of school rules and/or regulations.
For purposes of this policy, “drugs” shall include, but not be limited to:
Any student who violates the above may be subject to warning, reprimand, probation, suspension, or expulsion in addition to other civil and criminal prosecution.
Parents are encouraged to visit the school.
All visitors to the school must report to the office upon arrival.
The classroom teacher and Principal shall be informed as to the day and time of the visit so as to avoid any conflicts with the school schedule.
In visiting a classroom, parents must realize that the teacher’s first responsibility is to the children, and the teacher will be unable to converse at any length with the visitor. If a conference is desired, arrangements will be made by the teacher for an appointment with the parent either before or after school hours.
No person may enter onto school premises, including visits or audits to a classroom or other school activity, without approval by the Principal. Neither will any person be allowed to conduct or attempt to conduct any activity on school premises that has not had prior approval by the Principal.
Anyone who is not a student or staff member of the District, and is in violation of this policy, may be asked to leave the property of the District. Failure to comply with the lawful directions of District officials or of District security officers or any other law enforcement officers acting in the performance of their duties, and failure to identify one’s self to such officials or officers when lawfully requested to do so will be against District regulations. Failure to obey such instructions may subject the person to criminal proceedings applicable under the law.
The District does not permit classroom visits by children who are not students in the District.
Citizen of the Year
Students modeling exemplary behavior and responsibility will be rewarded. Qualifications include enrollment prior to October 1, no referrals to the discipline room, and teacher recommendation. These students will be rewarded at the end of the year.
Each school year it is the custom at Palo Verde School to allow the eighth grade to engage in fundraising activities, the proceeds of which are used for an end of year graduation trip. The amount of money raised by the class as a whole determines the destination. Obviously, the more money they raise the more elaborate the trip may become.
At the beginning of each school year the eighth grade sponsor will acquaint the students with the various alternatives in trip destinations, directly related to the amount of money raised by the class. The students’ suggestions for destinations and their diligence and success in raising funds will be the deciding factor for the annual trip.
If in the course of the school year an eighth grade student accumulates 15 or more absences that student will not be allowed to participate in the class graduation trip. In addition, if an eighth grade student is suspended from school for any reason they will be excluded from participation in the graduation trip. These are the minimum requirements; additional requirements will be explained to students.
There are four emergency classifications given to problems, which could occur at the nuclear power plant. The following terms explain each of the classifications. Unusual Event: A minor problem has taken place. No release of radioactive material to the atmosphere is expected. Small amounts of radioactive material could be released inside the plant. Alert: This is also a minor problem. Small amounts of radioactive material could be released inside the plant. Federal, state and county officials will be notified of the problem. Site Area Emergency: A more serious problem has taken place. Small amounts of radioactive material could be released near the plant. Government officials may direct special actions, sound the sirens and disseminate emergency information over radio and television broadcasts. General Emergency: This is the most serious kind of problem. Radioactive material could be released outside the plant site. Government officials will direct special actions, sound the sirens and disseminate emergency information over radio and television broadcasts.
School Procedures (for schools within the Emergency Planning Zone)
This handbook is meant to be a guide for students and parents. It is not all-inclusive of every rule, regulation, activity, and procedure that is followed on campus. Students may receive other information either verbally or in written form.
Palo Verde Elementary School and the parents of the students participating in activities, services, and programs funded by Title I, Part A of the Elementary and Secondary Education Act (ESEA) (participating children), agree that this compact outlines how the parents, the entire school staff, and the students will share the responsibility for improved student academic achievement and the means by which the school and parents will build and develop a partnership that will help children achieve the State’s high standards. This school-parent compact is in effect during school year 2019-2020.
Palo Verde Elementary School will:
We, as parents, will support our children’s learning in the following ways:
We, as students, will share the responsibility to improve our academic achievement and achieve the State’s high standards. Specifically, we will:
Estimado padre/madre o apoderado:
Valoramos su rol en el esfuerzo por ayudar a su hijo/a lograr altos criterios académicos. A continuaciờn se indican algunas de las formas en que usted y el personal de la escuela pueden crear y conservar una sociedad para compartir las responsabilidades de apoyar el aprendizaje de su hijo/a.
Responsabilidades de la escuela:
Responsabilidades de los padres:
Por favor revise este convenio entre las escuela y los padres con su hijo/a. Este convenio puede abordarse en una reuniờn de padres y maestros ya que tiene relaciờn con el progreso de su hijo/a.
Gracias por su apoyo y participación en las educaciờn de su hijo/a. Por favor comuníquese con la oficina de escuela para obtener mayor información.
STUDENT CONCERNS, COMPLAINTS,
(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.
Name ______________________________________ Date ____________
Telephone _________ Another phone where you can be reached __________
During the hours of _______________________________________________
Email address __________________________________________________
I wish to complain against:
Name of person, school (department), program, or activity ________________
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 all relevant dates, times, and places.
If there is anyone who could provide more information regarding this, 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
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