OAKLAND UNIFIED SCHOOL DISTRICT
1025 Second Avenue
Oakland, California 94606
APPEAL (LEVEL II & III)
Please complete the following form if there is a complaint or charge against any school site, program, office or school district employee. Appeals must be filed within five days of receiving the Level I Complaint response. Submit this complaint form to the District Ombudsperson at 1025 Second Avenue, Room 316A/B, Oakland, CA 94606. The telephone number is (510) 879-8685, FAX (510) 879-8035. Expect a response within ten (10) calendar days.
TO: District Ombudsperson
1025 Second Avenue - Room 316A/B
Oakland, CA 94606
FROM ______
Name(s)and Child(s) name
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Address
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Telephone Number(s)
Name of school, program or office or name of employee and job location against whom charge or complaint was directed: ______
* A copy of the written complaint against an employee will be provided to
the employee, except for sexual harassment and discrimination complaints.
Nature of appeal
______
Place a check next to the kind of complaint you are presenting:
Program: and/or Discrimination on basis of: and/or Other:
__ Adult Basic Education __ Age __ Student Suspension
__ Program for English Learners __ Ancestry and/or National Origin __ Student Expulsion
__ Career Technical & Technical Education __ Color
__ Child Care and Development __ Ethnic Group Identification ______
__ Child Nutrition __ Marital Status ______
__ Consolidated Categorical Programs __ Physical/Mental Disability
__ Educational Equity __ Race
__ Gifted and Talented Education (GATE) __ Religion
__ State Compensatory Education (SCE) __ Sex
__ School Improvement Program (SIP) __ Sexual Harassment
__ Migrant Education __ Sexual Orientation
__ Special Education __ Actual or Perceived Sex
__ Title I – No Child Left Behind __ Person’s association with a person or group
__ Safe and Drug Free Schools & Tobacco Use with one or more of these and
Prevention Education (TUPE) actual or perceived
characteristics
Page A-1
Questions regarding (check one) ___ Level I or ___ Level II Decision.
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Disagreement with (check one) ___ Level I or ___ Level II Decision.
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State the remedy or particular course of action you desire. Please be specific.
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I understand that the District will maintain this information confidential, to the extent provided by law or collective bargaining agreement; that I will be protected from retaliation for filing this complaint; that the District may request further information about this matter; and if such information is available, I agree to present it upon request.
I believe that the foregoing is true and correct.
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Signature Date
Page A-2
A11/18/09