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:  ____________________________