Appeal of Grievance Resolution Form

Background Information

Original date of the 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)

Grievance Information

Have you already submitted a Student Grievance Form that has been reviewed and you want to appeal the resolution provided following that review?(Required)

Yes No

This field is required.

Name of faculty or staff member that resolved your initial grievance.(Required) This field is required.

Select which concern applies:(Required)

Grade dispute Final grade appeal Issue with a 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.

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

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

What action are you requesting to rectify your grievance following the resolution that has already been provided?(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. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Background Information

Student Information

Grievance Information

Supporting Documentation

Submission