Student Grievance Form

Date of Report

Date of incident(Required):

This field is required.

Student Information

Please enter your information here. If you do not enter your information, your grievance will be received, but no additional action will be taken.

Name

Student ID Number

Phone number

Email address (@email.vccs.edu)

Type of Grievance

Before completing this form, every effort should be made to resolve the issue with the faculty or staff member informally. If after meeting informally with the faculty or staff member you are not satisfied with the outcome, please submit this form. Have you attempted to speak with the faculty or staff member?(Required)

Yes No

This field is required.

Name of faculty or staff member involved in this grievance. (List N/A if this does not involve a faculty or staff member)(Required) This field is required.

Select which concern applies:(Required)

Grade dispute Final grade appeal Issue with class Issue with instructor or staff member Issue with a college procedure

This field is required.

Class. (List N/A if this grievance does not apply to a class)(Required) This field is required.

Semester and Year:(Required) This field is required.

Please provide a description of your grievance.(Required) This field is required.

Indicate the action you are requesting to rectify the grievance.(Required) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Date of Report

Student Information

Type of Grievance

Supporting Documentation

Submission