Complaint initiated by: __________________________________________________________
Address: _______________________________________ Phone: ___________________
Person or school involved in complaint: ___________________________________________
1. What is the nature of your complaint? _____________________________________
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2. On what date, or over what period of time, did the alleged episode or offense occur?
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3. Have you taken any previous action regarding this matter? _________________________
If so, please explain: _______________________________________________________
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4. What suggestions do you have to resolve the problem?
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Signature: ________________________________________________
Date: ________________________________________________
12/21/2004 pw