Student Grievance Form

Student Complaints/Grievance Policy or Procedures

Prior to submitting a formal grievance, the student shall: consult the instructor whose action is being appealed. This consultation generally must take place within 14 calendar days of the start of classes after the grading period in question. The instructor is expected to meet in person or online with the student and respond to his/her grievance in writing within 10 calendar days.

If the student and the instructor are unable to reach agreement, or if the instructor is unwilling or unable to meet with the student, the student shall meet with the chair of the instructor’s department. If the instructor involved is the Department Chair or if there is no Department Chair, the student shall meet with the Provost/Chief Academic Officer involved. The Provost/Chief Academic Officer will meet with the student and with the instructor and recommend a solution to both the instructor and the student in writing within 10 calendar days.

All timelines for this process are suggested and may be extended for just cause.

A student seeking clarification or guidance regarding filing an academic grievance should contact the Student Services for assistance by completing the following form:

Student Name*

First NameLast Name

Student ID*

Academic Program*

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Date of incident*

Date

Place of Location (e.g. Specific Online Class or Physical Location):*

If this is a grievance against a specific person(s), please listtheir names and titles:

WHATACADEMIC POLICY, UNIVERSITY CODE OR POLICY, OR STUDENT RIGHT DO YOU ALLEGE HASBEEN VIOLATED?*

PLEASEEXPLAIN YOUR GRIEVANCE (Provide complete details and dates; present facts)*

WHATATTEMPTS HAVE YOU MADE TO RESOLVE THIS GRIEVANCE UP TO NOW? Please state who youcontacted and what transpired*

RESOLUTION SOUGHT

NOTE: RETALIATION AGAINST A STUDENT FOR MAKING A GRIEVANCE IS ABSOLUTELY PROHIBITED, AND WILL BE CONSIDERED A SERIOUS VIOLATION OF PROFESSIONAL RESPONSIBILITY

Certification

I hereby certify that the above information is true and correct to the best of my knowledge and belief. I grant permission for this complaint to be forwarded to UofSA officials for purposed of investigation and response

Signature: *

If completed online, your full name in this box will be considered your signature

Date*

Date

All information provided on this form is considered confidential until disclosure becomes necessary to proceed with resolution of the grievance.

If a complaint cannot be resolved after exhausting the institution’s grievance procedure, the student may file a complaint with the Bureau of Private Postsecondary Education. Unresolved complaints may be directed to the address below:

The Bureau for Private Postsecondary Education

Mailing Address:
Bureau for Private Postsecondary Education
P.O. Box 980818
West Sacramento, CA 95798-0818

Physical Address:
Bureau for Private Postsecondary Education
1747 North Market Blvd., Suite 225
Sacramento, CA 95834

Phone: (916) 574-8900
Toll Free: (888) 370-7589
Main Fax: (916) 263-1897

A student or any member of the public may file a complaint about this institution with the Bureau for Private Postsecondary Education by calling toll-free (888) 370-7589 or by completing a complaint to form, which can be obtained on the bureau’s internet web site (www.bppe.ca.gov).

Please verify that you are human*