Student Complaint Report Form
Students filing a complaint must first seek resolution of the complaint with the Faculty, Department Chair, Director of the Department or Dean of Student Affairs prior to submitting the student complaint form. If you have a complaint or concern as it applies to Board Policies, System President's Procedures, or College Procedures, please fill out this report.
Background Information
Name of Person Completing Report:
First Name
Last Name
S #
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of incident
*
-
Month
-
Day
Year
Date
Time of incident
Hour Minutes
AM
PM
AM/PM Option
Location of incident or concern
Involved Parties
Please list all individuals involved including yourself in the actual incident or concern.
1st party involved
2nd party involved
3rd party involved
4th party involved
Brief Description of Concern:
Department, Office or Individual with whom you have a concern.
*
Nature of Complaint:
*
Academic
Non-Academic
Financial
Other
If you choose "Other" above, please explain.
Identify all individuals with knowledge of the issue about which you are concerned:
Please describe your requested resolution for this concern.
*
Have you spoken with the Faculty, Department Chair, Director of the Department or the Dean of Student Affairs with regards to this complaint?
*
Yes
No
Submit
Should be Empty: