Henry County Board O F Education Certificated Employe E Complaint Form printable pdf download

Henry County Board O F Education Certificated Employe E Complaint Form

HENRY COUNTY BOARD OF EDUCATION

CERTIFICATED EMPLOYEE COMPLAINT FORM

Name of Complainant ___________________________________________________________

Mailing Address ________________________________________________________________

Home Phone _______________ Cell Phone _______________ Work Phone ________________

Email Address _______________________ Department or School ________________________

Position _______________________________________________________________________

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Under separate cover, please respond to the following. Please attach additional statements

and/or evidence that may substantiate your declaration.

1. Give reference or description of statute, policy, rule or regulation alleged to have been

violated or misapplied:

2. Give a brief statement of allegations showing the violation or misapplication of the

statute, policy, rule or regulation.

3. Give statement as to how the alleged violation or misapplication substantially affects

complainant in the employment relationship.

4. Give state of relief sought by complainant.

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The undersigned certificated employee hereby makes this complaint pursuant to Henry County

Board of Education Policy GAE and shows that the facts stated above are true and correct.

__________________________________________

______________________________

Employee’s Signature

Date

__________________________________________

______________________________

Administrator’s Signature

Date

Henry County Board O F Education Certificated Employe E Complaint Form