STUDENT GRIEVANCE FORM
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’s 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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