555 Franklin St. San Francisco, CA 94102 * Phone: (415) 241-6150 * Fax: (415) 241-6149

Cohorts N/A #1 N/A #2 N/A #3 N/A DATE:_ _

MS:N/A H.S:N/A B. Zone N/A Mis. Zone:N/A EED: N/A N/A Office of Family Voice Family Concern Documentation Form

THIS COMPLETED FORM BELONGS TO THE OFFCE OF FAMILY VOICE (OFV) AND CONTAINS INFORMATION THAT IS CONFIDENTIAL AND/OR PRIVILEGED. IF YOU ARE NOT THE INTENDED RECIPIENT, PLEASE NOTIFY YOUR SITE SUPERVISOR AND OFV IMMEDIATELY. THANK YOU FOR YOUR COOPERATION. NAME OF STUDENT (S) GRADE DOB: (MM/DD/YY) N/A

Programs: N/A Other: Parent or Guardian’s Name: Phone Number: Email:

Description of concern : OFFICE USE ONLY Category of Concern: Academics

Behavioral: N/A Other:

Climate/Culture N/A

Demographics N/A

Equity N/A

Other:

Other type of concerns Health issue Transportation

Describe your desired solution:

OFFICE USE ONLY Active Reopen Under investigation  Inconclusive  Closed CONCERN WAS RECEIVED Walked-in Other:

ACTION TAKEN: DATE:_

Ramon Martinez [email protected] 555 Franklin St. San Francisco, CA 94102 * Phone: (415) 241-6150 * Fax: (415) 241-6149 * Cell: (415) 793- 3298 INSTRUCTIONS Writing effective complaints:

1) Start with what you know (What you saw, heard, or said) 2) Use dates and times 3) Describe the steps you took to correct the problem 4) List the witnesses (If any) 5) Identify the rule of conduct or policy violation 6) Describe your desired solution

It is important to keep a log of any interactions and responses from your school and/or district.

 What type of interaction did you have (phone, in person meeting, email)?

 What day and time did the interaction occur?

 Who was included in the interaction? (Teacher, principal, other staff members or other adults)

 What, if any, documentation was submitted? (Police record, photograph, doctor’s note, etc.)

 Who was the documentation submitted to?

 What action were you told would be taken, and within what time frame?

 What actually happened and when did it happen?

 What are the next steps you need to take?

Parent Concern Levels:

LEVEL 1: It is best to start at the school level. When the concern or School Level complaint involves the school itself, going directly to the source can offer the immediate opportunity for resolution and/or greater understanding.

LEVEL 2: YOU ARE HERE Office of To report a concern or complaint not specific to any school, but district Family Voice wide or to seek support when unsatisfied with the response at the school level.

LEVEL 3: To have a concern or complaint reviewed by the Asst. Supt., who supervises LEADLEAD OfficeOffice (School(School the school leadership to assess the appropriateness of the response for Supervision) Supervision) which the parent is unsatisfied.

LEVEL 4: Level reserved for the highest or the most serious concerns that have Office of Deputy failed to reach resolution or satisfaction at ALL previous levels. Superintendent