2. Describe the Alleged Grievance









Please exercise care in completing this form. Take the time to print or write clearly.



Student Name:  

Student's Identification Number:

Today's Date:

Date of the Alleged Grievance:

Location of the Alleged Grievance:

Time of the Alleged Grievance:

Name of the Respondent:




Describe the Alleged Grievance



Instructions:  Be specific. Describe clearly the alleged grievance. (If necessary, seek assistance from a person of your choice in preparing this form.)


Please attach to this form any written and signed statements or other evidence which support your description of the alleged grievance.


Note: If you have already completed and turned in a Student Incident Report (Form 2530/001) and have no additional information to provide you may check here: ________ and just sign and date the form on the reverse side.







Form 2530/003 (front) (3/08)











What remedy/solution are you seeking?





Please list all attachments you are including with this form






Signature: _________________________________  Date: ________________________________


Form 2530/003 (back) (3/08)


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