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Student Grievance Form

Student Grievance Form

This form is to be used by students requesting a formal hearing as outlined in the Student Complaint and Grievance Procedures. This form, when completed, will be submitted to the Office of Student Services, Blake Center. Information and assistance in completing the grievance statement below may be obtained from the Office of Student Services.

For a full definition, please review the university’s published student grievance policies and procedures in the student's handbook.

COMPLAINANT INFO

GRIEVANCE AGAINST THE GRADE/ACTION OF (please check)

PERSON WHO DISCRIMINATED AGAINST YOU:

IF NOT GRADE GRIEVANCE- Description of Complaint:


If this is not a grade grievance, briefly state your complaint.

PREVIOUS ACTION:


Have you brought this matter to the attention of any other department(s) at the university? If so, please list the name(s) and department(s) of all other persons with whom you have discussed this matter.

Complaint Documentation:


Explain any documentation supporting your complaint.

Corrective Action Sought:


Describe the corrective action you are seeking.

Witnesses:


(Relationship=co-worker, supervisor, classmate, faculty, etc.)

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