Teachers Name:_______________________________________________________________
Students Name:_______________________________________________________________
Class:________________________________________________________________________
Date:_________________________________________________________________________
I have reviewed the request for a grade change and the reasons for which the change is requested. I have reviewed my grade book and grading criteria. Based on that information, I have decided that a change in grade (is) (is not) justified for the following reasons (attach more sheets, if necessary):
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Teachers Signature Date
12/21/2004 pw