Complaint Form

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Complaint Form

Per MSBA/MASA Model Policy 103 adopted by District #542

Complaints-Students, Employees, Parents, Other Persons

This form may be used as part of the Board's Complaint / Grievance Procedure by students,
employees, parents, and other persons who wish to initiate a formal written complaint with ISD #542.

Date *

YYYY

Name of Student/Complainant Party: *

Parent/Guardian *

Address *

Telephone *

Please provide a complete description / explanation of the complaint, including the date of the
incident on which the complaint is based, names of others responsible or involved in the incident,
names of witnesses, and all other relevant facts.
*

Describe, if any, earlier efforts you have done to resolve this matter or the reasons no such efforts
were pursued. (include dates, times)
*

What specific remedy or corrective action are you seeking?
*

First and Last name of person completing the form *

I confirm that the name entered above corresponds to the individual who completed this form.
*

Yes

Submit

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