Receipt Form for Work Rendered

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					    Office of the Superintendent of Schools
   MONTGOMERY COUNTY PUBLIC SCHOOLS                                                        ADMINISTRATIVE COMPLAINT
           Rockville, Maryland 20850

INSTRUCTIONS: Please print or type. For additional information see Regulation GKA-RA: Administrative Complaint.
Call 301-279-3511 for register number

To be completed by complainant
                                        Name of
Register number                         Complainant                                                Date of alleged violation      /          /

Social Security No.         -       -

Administrative regulation violated

Description




Remedy requested




                                                                                                                       /      /
                                   Signature, Complainant                                   Work Location                  Date

LEVEL I: ADMINISTRATIVE DISPOSITION – To be completed by principal or immediate supervisor

Date received      /    /          Initials
   Granted        Denied        If denied, give reason


                                                                                                            /      /
                                              Signature, Principal/Immediate Supervisor                     Date

Reply received by complainant            /       /                                   Copies distributed to parties in interest    /          /
                                         Date             Initials                                                                    Date

LEVEL II: ADMINISTRATIVE DISPOSITION – To be completed by associate superintendent/department director

Date received      /    /          Initials
   Granted        Denied        If denied, give reason


                                                                                                            /      /
                                   Signature, Associate Superintendent/Department Director                  Date

Reply received by complainant            /       /                                   Copies distributed to parties in interest    /          /
                                         Date             Initials                                                                    Date

LEVEL III: ADMINISTRATIVE DISPOSITION – To be completed by superintendent/designee

Date received      /    /          Initials
   Granted        Denied        If denied, give reason


                                                                                                            /      /
                                                Signature, Superintendent/Designee                          Date

Reply received by complainant            /       /                                   Copies distributed to parties in interest    /          /
                                         Date             Initials                                                                    Date

MCPS Form 430-42, Rev. 4/01
                                    ADMINISTRATIVE COMPLAINT

No administrative complaint shall be initiated more than 15 school days after the cause has occurred
or should have been discovered.

LEVEL ONE                                                  4. Within ten (10) school days after the meeting, the
                                                              appropriate administrator:
1. If the complaint cannot be adjudicated through the
   informal process, the complainant obtains a regis-         a) Completes the appropriate section, Administra-
   ter number from the Department of Association                 tive Disposition, of the form
   Relations and completes MCPS Form 430-42: Ad-
   ministrative Complaint.                                    b) Returns the original form to the complainant

2. The complainant submits the completed form to           5. The complainant completes the appropriate sec-
   the principal or immediate supervisor within five (5)      tion of the form, acknowledging receipt of the re-
   school days after the informal discussion.                 sponse to the complaint, and returns the original
                                                              document to the appropriate administrator.
3. Upon receipt of the written complaint, the principal
   or immediate supervisor:                                6. The appropriate administrator distributes copies of
                                                              the completed form to all parties in interest and re-
   a) Initials and dates the form                             turns the original document to the complainant.
   b) Provides a copy of the complaint to the com-         LEVEL THREE
      plainant
                                                           1. If the complainant is not satisfied with the disposi-
4. The principal or immediate supervisor has ten (10)         tion of his complaint at Level Two, or if no decision
   school days to:                                            has been rendered within ten (10) school days af-
                                                              ter the meeting with the appropriate administrator,
   a) Review the written complaint                            the complainant may submit the complaint to the
   b) Complete the appropriate section, Administra-           superintendent.
      tive Disposition, of the form                        2. Upon receipt of the written complaint, the superin-
   c) Return the original form to the complainant             tendent, or his/her designee.
5. The complainant completes the appropriate sec-             a) Initials and dates the form
   tion of the form, acknowledging receipt of the re-         b) Provides a copy of the complaint to the com-
   sponse to the complaint, and returns the original             plainant
   document to the principal or immediate supervisor.
                                                           3. Within 10 (10) school days after receiving the writ-
6. The principal or immediate supervisor distributes          ten complaint, the superintendent, or his/her des-
   copies of the completed form to all parties in inter-      ignee, meets with the complainant for the purpose
   est and returns the original to the complainant.           of resolving the complaint
LEVEL TWO                                                  4. Within ten (10) school days after the meeting, the
1. If the complainant is not satisfied with the decision      superintendent, or his/her designee:
   at Level One, or if no decision has been rendered          a) Completes the appropriate section, Administra-
   within ten (10) school days after presentation of             tive Disposition, of the form
   the written complaint, the complainant may file the
   complaint with the appropriate administrator (asso-        b) Return the original form to the complainant
   ciate superintendent or department director).
                                                           5. The complainant completes the appropriate sec-
2. Upon receipt of the written complaint, the appropri-       tion of the form, acknowledging receipt of the deci-
   ate administrator:                                         sion concerning the complaint, and returns the
                                                              original document to the superintendent or desig-
   a) Initials and dates the form                             nee.
   b) Provides a copy of the complaint to the com-         6. The superintendent, or his/her designee, distrib-
      plainant                                                utes copies of the completed form to all parties in
3. Within ten (10) school days after receiving the writ-      interest and returns the original document to the
   ten complaint, the appropriate administrator meets         complainant.
   with the complainant for the purpose of resolving
   the complaint.

				
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Description: Receipt Form for Work Rendered document sample