Complaint Form
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Parents, students and staff work together frequently to address concerns and improve the educational experience for students. Raising concerns directly with the involved employee, school or department is often the most effective way to resolve them.
While problem-solving at the local, school level is encouraged, some complaints are not resolved at the local level and in some circumstances, a person may wish to raise their concern with district administration immediately.
The superintendent’s office will send you a written acknowledgement, within 10 working days of receiving this form, telling you who will follow up on your complaint.
Please correct the following errors.
Information about complainant
First name
Last name
Person reporting:
Student
Parent
Employee
Volunteer
Other (Please specify)
I am filing this complaint on behalf of:
Myself
My child
Another Student
Other (Please specify)
Please provide your contact information:
Street 1
City
ZIP
Telephone e.g. (123) 456-7890
Email Address
Date of Complaint:
(MM/DD/YYYY)
Type of complaint
Please check the appropriate box.
Legal Compliance (Alleged noncompliance with Oregon school regulations (OAR 581-022 Program Standards) or other law applicable to district programs. Examples include: Special Education, Talented and Gifted, Alternative Education, Instructional Hours, Health and Safety, Nutrition, Restraint and Seclusion, or Title IX.
Bullying, harassment, intimidation, cyberbullying or hazing not based on a legally protected characteristic.
Discrimination or harassment based on a legally protected characteristic (Please check the actual or perceived characteristic upon which the alleged conduct was based).
Other (Please specify)
(Discrimination continued) Please check the actual or perceived characteristic upon which the alleged conduct was based.
Age
Disability
Gender identity or expression
Marital status
Military or veteran status
National origin
Pregnancy
Race or ethnicity
Religion
Retaliation
Sex or gender
Sexual harassment
Sexual orientation
Other (Please specify)
Details of complaint
What happened? Please describe the incident or concern you experienced that led to this complaint, including the events and actions in as much detail as possible.
Are you making a complaint about a specific staff person?
Yes
No
Name of Staff Member
Who was involved in the incident or concern?
Who witnessed it?
Where did it happen?
When did it happen and/or when did you learn about it?
Have you attempted to resolve the incident or concern at the school level?
Yes
No
Who did you talk to? What were the results?
Why not?
How would you like the district to resolve your complaint?
What would you like to submit?
Question
Comment
Suggestion
Concern
Compliment
Tell us who you are
(Select one or more)
Eugene School District 4J Student
Eugene School District 4J Parent/Guardian
Eugene School District 4J Employee
Community Member
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