STUDENT GRIEVANCE FORM
Please exercise care in completing this form. Take the time to print or write clearly.
Student Name:
Student's Identification Number:
Today's Date:
Date of the Alleged Grievance:
Location of the Alleged Grievance:
Time of the Alleged Grievance:
Name of the Respondent:
Describe the Alleged Grievance
Instructions: Be specific. Describe clearly the alleged grievance. (If necessary, seek assistance from a person of your choice in preparing this form.)
Please attach to this form any written and signed statements or other evidence which support your description of the alleged grievance.
Note: If you have already completed and turned in a Student Incident Report (Form 2530/001) and have no additional information to provide you may check here: ________ and just sign and date the form on the reverse side.
Form 2530/003 (front) (3/08)
(continued)
What remedy/solution are you seeking?
Please list all attachments you are including with this form
Signature: _________________________________ Date: ________________________________
Form 2530/003 (back) (3/08)