Student Grievance Form
Name
*
First Name
Last Name
Student ID No.
*
Student Email Address
*
Term
*
Please Select
02A
04A
06A
08A
10A
12A
Date
*
-
Month
-
Day
Year
Date
Name of person/s whom grievance is reported against
Type of grievance
*
Non-academic Policy
Academic grievance policy
If an academic grievance is submitted, did you speak with your professor regarding the issue before starting the grievance process?
*
Yes
No
If you answered Yes for the previous question, how was the grievance handled?
*
By Phone
In person meeting
Email
Other
Were there any witnesses? If yes, please provide Information
Yes
No
Not Applicable
Witness information
Account of Event - Describe in detail what your grievance is concerning
*
0/350
Attach any documents related to the grievance that you feel would be appropriate to thiscase for review
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature
*
Submit
Administration Section
Date of Resolution
-
Month
-
Day
Year
Date
Resolution Outcome
Please Select
Appeal rejected-letter sent
Appeal accepted-letter sent
Other (Further Investigation needed
Committee Chair
First Name
Last Name
Name of Chair Members
Please Select
Dr. Lee Smith
Dr. Sergei Andronikov
Dr. Svetlana Mitereva
Grievance Status
Open
Closed
Submit
Should be Empty: