Student Grievance Form

First & Last Name

Campus Key

Email Address

Telephone

Other - (more info)

Date of Event (if applicable)

Description of Grievance *

If Policy Violation or Request for an Exception to Policy please indicate the policy here.

Request for Policy Exception?

Yes

Is there any supporting information available?
For example, regarding your grievance, documents, etc?

Please indicate what steps you have taken to address your grievance.
Check all that apply.

None taken

Met with person closest to the issue

Met with other department member(s) to address the issue

Have been referred to fill out this form

Describe previous steps taken:

What do you feel is an appropriate outcome to this grievance?*

By my e-signature I verify this information to be accurate to the best of my knowledge.

I agree:

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