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<!DOCTYPE HTML PUBLIC "-//IETF//DTD HTML//EN">
<html>
<head>
<meta http-equiv="Content-Type"
content="text/html; charset=iso-8859-1">
<meta name="GENERATOR" content="Microsoft FrontPage 2.0">
<title>Complaint Procedure Fore</title>
</head>
<body>
<h1><font color="#008080">West Contra Costa Unified School
District</font></h1>
<h1><font size="5">Uniform Complaint Procedure Form</font><font
size="1"><strong> (Programs &amp; Policies)</strong></font></h1>
<p><font size="5"><strong>Parent Complaint Procedure Form</strong></font><font
size="2"><strong> </strong></font><font size="1"><strong>(District
Employees)</strong></font></p>
<hr>
<p>This form should acompany all formal complaints against
District programs, policies, or employees. Instructions for
filing a <a href="http://www.wccusd.k12.ca.us/comproun.htm">Uniform
complaint</a> or <a
href="http://www.wccusd.k12.ca.us/compropa.htm">Parent Complaint </a></p>
<form action="--WEBBOT-SELF--" method="POST">
<!--webbot bot="SaveResults" u-file="formrslt.htm"
s-format="HTML/DL" b-label-fields="TRUE" --><input
type="hidden" name="Comments:" value="Comments:"><p>&nbsp;</p>
<blockquote>
<table border="0">
<tr>
<td align="right"><em>Name of Complainant</em></td>
<td><input type="text" size="35"
name="Contact_FullName"> </td>
</tr>
<tr>
<td align="right"><em>Title</em></td>
<td><input type="text" size="35"
name="Contact_Title"> </td>
</tr>
<tr>
<td align="right"><em>Organization</em></td>
<td><input type="text" size="35"
name="Contact_Organization"> </td>
</tr>
<tr>
<td align="right"><em>Street address</em></td>
<td><input type="text" size="35"
name="Contact_StreetAddress"> </td>
</tr>
<tr>
<td align="right"><em>Address (cont.)</em></td>
<td><input type="text" size="35"
name="Contact_Address2"> </td>
</tr>
<tr>
<td align="right"><em>City</em></td>
<td>Choose one of the following cities:<blockquote>
<p><select name="City" size="1">
<option selected> El Cerrito </option>
<option> El Sobrante </option>
<option> Hercules </option>
<option> Kensington </option>
<option> Pinole </option>
<option> Richmond </option>
<option> San Pablo </option>
</select> <br>
</p>
</blockquote>
</td>
</tr>
<tr>
<td align="right"><em>State</em></td>
<td><input type="text" size="35"
name="Contact_State"> </td>
</tr>
<tr>
<td align="right"><em>Zip/Postal code</em></td>
<td><input type="text" size="12" maxlength="12"
name="Contact_ZipCode"> </td>
</tr>
<tr>
<td align="right"><em>Work Phone</em></td>
<td><input type="text" size="25" maxlength="25"
name="Contact_WorkPhone"> </td>
</tr>
<tr>
<td align="right"><em>Home Phone</em></td>
<td><input type="text" size="25" maxlength="25"
name="Contact_HomePhone"> </td>
</tr>
<tr>
<td align="right"><em>FAX</em></td>
<td><input type="text" size="25" maxlength="25"
name="Contact_FAX"> </td>
</tr>
<tr>
<td align="right"><em>E-mail</em></td>
<td><input type="text" size="25"
name="Contact_Email"> </td>
</tr>
</table>
</blockquote>
<table border="0">
<tr>
<td align="right"><em>Name of Student</em></td>
<td><input type="text" size="25" name="Contact_Email">
</td>
</tr>
</table>
<p>Name of School: Choose one of the following schools:</p>
<blockquote>
<p><select name="School" size="1">
<option>Administration Building</option>
<option selected> Adams </option>
<option> Bayview </option>
<option> Castro </option>
<option> Chavez </option>
<option> Collins </option>
<option> Crespi </option>
<option> De Anza </option>
<option> Delta </option>
<option> Dover </option>
<option> Downer </option>
<option> El Sobrante </option>
<option> Ellerhorst </option>
<option> Farimont </option>
<option> Ford </option>
<option> El Cerrito </option>
<option> Gompers </option>
<option> Grant </option>
<option> Hanna Ranch </option>
<option> Harding </option>
<option> Helms </option>
<option> Hercules </option>
<option> Highland </option>
<option> Kappa </option>
<option> Kensington </option>
<option> Kennedy </option>
<option> King </option>
<option> Lake </option>
<option> Lincoln </option>
<option> Madera </option>
<option> Middle College </option>
<option> Mira Vista </option>
<option> Montalvin </option>
<option> Murphy </option>
<option> North Campus </option>
<option> Nystrom </option>
<option> Ohlone </option>
<option> Olinda </option>
<option> Omega </option>
<option> Peres </option>
<option> Pinole Middle </option>
<option> Pinole Valley High </option>
<option> Portola </option>
<option> Richmond </option>
<option> Riverside </option>
<option> Seaview </option>
<option> Shannon </option>
<option> Sheldon </option>
<option> Sigma </option>
<option> Stege </option>
<option> Stewart </option>
<option> Tara Hills </option>
<option> Valley View </option>
<option> Verde </option>
<option> Vista </option>
<option> Washington </option>
<option> Wilson </option>
</select> <br>
</p>
<p>&nbsp;</p>
</blockquote>
<p><strong>If the complaint is against a program or policy,
please follow the instructions in the Uniform Complaint
Procedure and complete either Section A or Section B below.</strong></p>
<p>Section A: I am filing a complaint alleging a violation of
federal or state statutes related to this program:</p>
<table border="0">
<tr>
<td align="center"><em>Program Name: </em></td>
<td align="center"><input type="text" size="25"
name="Contact_Email"> </td>
</tr>
</table>
<blockquote>
<p><select name="talked " size="1">
<option selected> I have </option>
<option> I have not </option>
</select> discussed this with the principal/program
manager.<br>
</p>
</blockquote>
<p>Section B: I am filing a complaint allleging a violation
of a board policy related to:</p>
<table border="0">
<tr>
<td align="center"><em>Policy Name: </em></td>
<td align="center"><input type="text" size="25"
name="Contact_Email"> </td>
</tr>
</table>
<blockquote>
<p><select name="talked " size="1">
<option selected> I have </option>
<option> I have not </option>
</select> discussed this with the Special Assisatnat to
the Superintendent.</p>
<p>&nbsp;</p>
</blockquote>
<p>If the complaint is against a district employee, plesase
follow the instructions of the Parent Complaint Procedure. </p>
<p>I am filing a complaint against </p>
<table border="0">
<tr>
<td align="center"><em>Employee Name: </em></td>
<td align="center"><input type="text" size="25"
name="Contact_Email"> who is working at <select
name="D1" size="1">
<option selected> Adams </option>
<option> Bayview </option>
<option> Castro </option>
<option> Chavez </option>
<option> Collins </option>
<option> Crespi </option>
<option> De Anza </option>
<option> Delta </option>
<option> Dover </option>
<option> Downer </option>
<option> El Sobrante </option>
<option> Ellerhorst </option>
<option> Farimont </option>
<option> Ford </option>
<option> El Cerrito </option>
<option> Gompers </option>
<option> Grant </option>
<option> Hanna Ranch </option>
<option> Harding </option>
<option> Helms </option>
<option> Hercules </option>
<option> Highland </option>
<option> Kappa </option>
<option> Kensington </option>
<option> Kennedy </option>
<option> King </option>
<option> Lake </option>
<option> Lincoln </option>
<option> Madera </option>
<option> Middle College </option>
<option> Mira Vista </option>
<option> Montalvin </option>
<option> Murphy </option>
<option> North Campus </option>
<option> Nystrom </option>
<option> Ohlone </option>
<option> Olinda </option>
<option> Omega </option>
<option> Peres </option>
<option> Pinole Middle </option>
<option> Pinole Valley High </option>
<option> Portola </option>
<option> Richmond </option>
<option> Riverside </option>
<option> Seaview </option>
<option> Shannon </option>
<option> Sheldon </option>
<option> Sigma </option>
<option> Stege </option>
<option> Stewart </option>
<option> Tara Hills </option>
<option> Valley View </option>
<option> Verde </option>
<option> Vista </option>
<option> Washington </option>
<option> Wilson </option>
</select> <br>
</td>
</tr>
</table>
<p>Please write comments in the white field below:</p>
<blockquote>
<blockquote>
<p><textarea name="Comments" rows="15" cols="40"></textarea><br>
</p>
</blockquote>
</blockquote>
<p>Please print this form and mail to : </p>
<p><strong>West Contra Costa Unified School District </strong></p>
<p><strong>Area Director</strong></p>
<p><strong>1108 Bissell Avenue</strong></p>
<p><strong>Richmond, CA 94801</strong></p>
<p>&nbsp;</p>
</form>
<hr>
<h5>Copyright WCCUSD 1998. All rights reserved.<br>
Last revised: <!--webbot bot="TimeStamp" startspan
s-type="EDITED" s-format="%B %d, %Y" -->September 15, 1998<!--webbot
bot="TimeStamp" i-checksum="39092" endspan --></h5>
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