COTC Concern and Feedback Form

COTC Concern and Feedback Form
Campus Area of Concern: (Select all that apply)

Faculty/StaffStudent LifeFacilities/Campus GroundsSafety and SecurityOther
COTC ID Number:
Chosen Name

First NameLast Name
Email*

Confirmation EmailEnter email twice to confirm (lastname-#@cotcmail.cotc.edu)
Phone Number

Area CodePhone Number
Date of incident (for multiple dates, select when the incident(s) began to occur)

MonthDayYear
Date
Campus Location
Building/Room/Area of incident*
If the concern/feedback involves a campus academic course or faculty member, please complete the following information:
Course
subject code/number/section
Course days/times:
Describe the concern/feedback in detail. Include name of person(s), locations and dates involved. If the feedback/concern is about a specific person(s), please list name and any applicable title.*
What attempts have you made to resolve this concern up to now? Please state who you contacted and the details, including any relevant information, needed for the review of your complaint/concern.
Any other information that you would like to provide?
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For feedback/concerns pertaining to an academic course or faculty member, please provide the course syllabus.
Browse Files

Cancelof
Would you like to request a meeting with area supervisor?*

YesNo
Signature*

Clear
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/concern to be forwarded to Central Ohio Technical College officials for purposes of investigation and response.
Academic Affairs - Reply-To
Verification Code (Office Use Only)
Description
Date

MonthDayYear
Date
Should be Empty:

COTC Concern and Feedback Form

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