1. STUDENT GRIEVANCE FORM
    2. Describe the Alleged Grievance

 

 

 


NOTE: This form is not submitted until after the student has submitted an online Student Complaint Form  and the College has concluded mediation procedures in accordance with the College‚Äôs Student Grievance Procedures policy.

 

 
  


 






 
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 submitted an online Student Complaint Form and have no additional information to provide you may check here: ________ and just sign and date the form on the second page.
Form 2530/003 (page 1 of 2) (12/12)
Describe the Alleged Grievance (Continued):
What remedy/solution are you seeking?
Please list all attachments you are including with this form
Signature: _________________________________ Date: ________________________________
Form 2530/003 (page 2 of 2) (12/12)

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