K-1381   ©   KE-E  

EXHIBIT

PUBLIC  CONCERNS  AND  COMPLAINTS

(This Form to be Submitted to the Superintendent)

Person(s) or group filing complaint   ____________________________________

Complainant's address   _________________________   Phone   ________________

Complainant's E-mail address   ____________________________________________

Date complaint is filed   ________________________________________________

Has problem been discussed with the administration?

¨ Yes  ¨ No                          Date __________________________________________

Summary of the charges (description of incident or event, including date, place, time, additional persons, alleged problem, and suggested solution):

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Identification of other witnesses or persons with information about concern:

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The projected solution

Indicate what you think can and should be done to solve the problem.  Be as specific as possible.

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Signature of complainant   Date

The administration shall give one (1) copy to the complainant and shall retain one (1) copy for the file.