Evaluation Grievance Process - Step I

RUTHERFORD COUNT YSCHOOLS

 

Evaluation Grievance Form - Step I

 

This form must be completed by the grievant and submitted to the evaluator no later than fifteen (15) days following the summative evaluation.

 

Name of Grievant:  __________________________________________________

 

School:  ___________________________________________________________

 

Name of Evaluator:  _________________________________________________

 

Date Evaluation Received:  ____________ Evaluation Period:  _______________

 

Basis for grievance:  Identify the inaccurate data that was used or describe the procedural error that occurred as pat of your evaluation.  Explain how this inaccurate data or procedural error materially affected or compromised your evaluation.  ________________________________________________________________________

 

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(Attach additional sheets or documentation as needed)

 

Corrective Action Desired:  _________________________________________________

 

________________________________________________________________________

 

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Signature of Grievant:  _____________________________________________________

 

TO BE COMPLETED BY THE EVALUATOR

 

Date received:  ____________ Grievance Disposition:  Confirmed _____ Denied______

 

Corrective action taken:  ___________________________________________________

 

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Signature of evaluator:  ____________________________________________________

 

Date grievant notified:  ____________________________