Fillable COMPLAINT FORM Concerning Staff or Programs (Policy 4220)

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COMPLAINT FORM Concerning Staff or Programs (Policy 4220)

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MOSES LAKE SCHOOL DISTRICT
1620 S. PIONEER WAY • MOSES LAKE, WA 98837 • 509.766.2650 • MLSD161.ORG
COMPLAINT FORM
Concerning Staff or Programs (Policy 4220)
Name
Date
Email
Phone
Address
City/State/Zip
I wish to register a complaint against:
Name of person, school, department, program, etc:
Complaint Details:
Specify your complaint by stating the problem as you see it. Describe the incident, participants, background to the
incident, and any attempts you have made to resolve the problem. Please note relevant dates, times, and places.
Witnesses:
Please list anyone who can provide additional information regarding your complaint.
Name
Email
Phone
Proposed Solution:
Indicate your opinion on how this problem might be resolved. Please be as specific as possible.
I certify that there is no falsification of the above information and events are accurately depicted to the best of my
knowledge.
Signature
Date
Submit the completed form to mmusso@mlsd161.org or bring a hard copy to the Learning Services Center at 1620 S.
Pioneer Way, Moses Lake. Please see District Procedure 4220P for information concerning the processing of
complaints.
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COMPLAINT FORM Concerning Staff or Programs (Policy 4220)

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Completed 18 May 2022

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