Adopted: 11-9-76
Reviewed: 8-13-03
This form is to be prepared by or for any individual who wishes the District to review the services provided by an employee or by a program of the District.
I wish to have the District review the services being provided by: (Individual)
or by: (Program)
Date:
Name:
Tel. No.
Address:
1. These are my specific concerns:
2. I have review/discussed these concerns with the following school district employees:
3. These are my recommendations:
4. I have observed the situation myself. Yes /No
5. If this information is prepared by someone other than the individual requesting the review, how was the information gathered?
Telephone, face-to-face, other (specify)
6. Signature of person completing form