I, the undersigned, a patron of _________ Unified School District No. _, do hereby make complaint and advise the administration and/or board of education that I understand and believe that:_______________________________________________________ a teacher, employee, or policy of said district, on or about the _____ day of _________20, at_________________________________________________ did: (Please describe the incident or act complained of) ______________________________________________________________


I believe this incident, act, or policy adversely affects the performance of said teacher, employee, or district as follows: (Please describe how you believe the action complained of has an adverse effect.) ________________________________________________________________


Complaint form USD ____Page Two

Prior to signing this complaint, I have taken the following action to verify the occurrence and remedy or clarify the problem complained of: (Generally, this should include discussing the incident with: 1-the teacher, 2-the building principal, and 3-the superintendent.) ______________________________________________________________

I suggest the following action on behalf of the administration and/or board: ________________________________________________________________

[NOTE: The signed individual's testimony may not be required in some cases, for example complaints concerning discrimination and sexual harassment.]

Complainant signature:_________________________________________Date:_______ 

Administrator signature:_________________________________________Date:_______