Code No 215.E1
Riverside Community School District
General Complaint by a Citizen
Complainant Name:__________________ Signature: ________________________
Complainant Address:_________________________________________________________
Home Telephone:____________________ Work Telephone:____________________
Today's Date:______________________ Date Situation Occurred:___________
In the space provided describe the situation in question:____________________
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What solution do you seek?___________________________________________________
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Response by 1st district employee to handle situation:_______________________
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Employee Signature:____________________________
Date: _________________________________________
If not resolved earlier, Supervisor/Principal Comments:______________________
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Supervisor/Principal Signature:______________________________________________
Date:__________________________________________
If not resolved earlier, Superintendent's Comments:__________________________
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Superintendent’s Signature:________________________________
Date:__________________________________________
Reviewed: 4-18-2022