Full Name
First Name
Last Name
Student ID
E-mail
Home phone
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Area Code
Phone Number
Cell phone
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Area Code
Phone Number
Date of incident that prompted this complaint
*
-
Month
-
Day
Year
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Individual and/or department involved
Description of incident
*
What are your primary concerns/issues?
Have you shared your concerns with the reported indvidual or department?
*
Yes
No
Have you attempted to work with them to resolve the concerns/issues?
*
Yes
No
Would you like to propose a resolution?
*
Yes
No
Describe your proposed resolution.
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