1. INSTRUCTIONS:  This form is completed by the Department Chair or Division Dean (or their designees). The form is used to document the process and outcome regarding resolution of a student’s complaint that is of an academic nature with a faculty member in whose class the student is currently enrolled, in accordance with the Student Academic Complaint Procedure. This form is used after the student has attempted to resolve the complaint directly with the faculty member.

 


ACADEMIC DIVISION STUDENT COMPLAINT FORM


INSTRUCTIONS:  This form is completed by the Department Chair or Division Dean (or their designees). The form is used to document the process and outcome regarding resolution of a student’s complaint that is of an academic nature with a faculty member in whose class the student is currently enrolled, in accordance with the Student Academic Complaint Procedure. This form is used after the student has attempted to resolve the complaint directly with the faculty member.

STUDENT INFORMATION
Student Name:     Method of Contact : ☐ in person   ☐   phone ☐   email  
LOLA #: Phone: Email:
Course, Number, and Section:
Instructor:
Date of Complaint:
Description of Complaint:   (Write a Summary of the Complaint. Indicate if attachments are included.)
 
 
 

Resolution Being Sought:   (Describe the resolution/remedy being sought.)
 
 

 

DEPARTMENT CHAIR OR DESIGNEE COMPLETES THIS SECTION
Resolution Process/Outcome Statement: (Describe resolution process, next steps offered to student, and outcome.)
 

 
 
 

DIVISION DEAN OR DESIGNEE COMPLETES THIS SECTION (IF APPLICABLE)
Resolution Process/Outcome Statement: (Describe resolution process, next steps offered to student, and outcome.)
 
 
 
 
   

DISPOSITION (Date ___________________________________):

____ Complaint resolved at Department Chair Level.  Dept. Chair/designee’s initials: ________

____ Complaint resolved at Division Dean Level. Division Dean/designee’s initials: __________

____ Complaint not resolved. Student referred to College Level process. Division Dean/designee’s initials: __________

Form 2530/005 (1/19)

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