Please respond to each of the following items (typing or clearly printing in ink):
1. Name
2.
Street Address City State Zip Code
3. Telephone Number: (__________)_________________________________________
4. Social Security Number
5. Date of Birth ______/______/______
6. What is the specific violation for which you are making this academic grievance? (Please refer to the definition of "academic grievance" on page 1 of the "Student Grievance Process.")
7. What is the date when the alleged incident or violation first occurred? _____/______/_____
8. Did you attempt to resolve the issue with the individual against whom grievance is directed?
Yes ( ) date of contact: ______/______/______ No ( )
9. Did you attempt to resolve the issue by contacting the appropriate Division Chair?
Yes ( ) date of contact: ______/______/______ No ( )
10. Please provide a complete description of the alleged incident, including copies of all supporting and relevant documents. Attach any additional pages necessary.
11. What specific redress or solution do you seek in making this academic grievance?
I hereby acknowledge that by signing this form, I am providing representatives of
______/______/______
Signature Date
The original copy of this form must be submitted to the Dean of Faculty through the Office of Academic Programs.
Office Use Only:
Date of Receipt: _________________________
Received by: ________________________________________________________
