Fillable ACADEMIC GRIEVANCE FORM A student who wishes to (Dillard University)

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ACADEMIC GRIEVANCE FORM A student who wishes to (Dillard University)

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ACADEMIC GRIEVANCE FORM
A student who wishes to raise a concern about an academic issue must initiate the process. The process requires the
student to complete an “Academic Grievance” form and submit it to the person, instructor, staff, or administrator
against whom the complaint is being made. If the grievance is resolved at that time, no further action is needed but
both student and respondent should keep a record of the complaint with copies forwarded to the offices of the Program
Coordinator, School Chair, College Dean, and Dean of Faculty and Student Academic Support Services, and Vice
President for Academic Affairs within five business days.
If the grievance is not resolved, the student should appeal to the supervisor of the person, against whom the complaint
is being made, (for example: if the unresolved grievance is against a faculty member, the student should appeal to the
program coordinator). If the grievance is resolved with this person, no further action is needed but, as above, a record
of the grievance and its resolution should be sent to the next lines of authority.
If the grievance is still not resolved, the same procedure may be used to appeal to the school chair, college Dean, and
the Dean of Faculty and Student Academic Support Services, respectively. If the matter remains unresolved, the
grievance may be appealed to the Vice President for Academic Affairs, whose decision is final. At each line of
authority, the Academic Grievance form is completed and moved to the next level by all involved in the grievance
process.
Student's Name: ______________________________ Email Address: _________________________
Phone Number: _________________________
Write a brief statement explaining the nature of your grievance, including any prior actions (use additional sheets if
needed):
List the documents that support your position (list them here and attach copies. Do not submit originals):
Signature: _________________________________________ Date:__________________
Name of person against whom grievance is filed:____________________________________
First Respondent’s Name:_____________________________________________________
Title: __________________________________
Email:__________________________________
Phone: ______________________________
Action Taken (Use additional sheets if needed. Note: List them here and attach copies. Do not submit originals):
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ACADEMIC GRIEVANCE FORM – Page 2
Signature: ________________________________________________ Date: ________________
Second Respondent's Name: __________________________________
Title: ________________________________________
Email: _______________________________________ Phone: ______________________
Action Taken (Use additional sheets if needed. Note: List them here and attach copies. Do not submit originals):
Signature: ______________________________________________ Date:__________________
Third Respondent's Name: _____________________________________
Title: _________________________________________
Email: ________________________________________ Phone: ____________________
Action Taken (Use additional sheets if needed. Note: List them here and attach copies. Do not submit originals):
Signature: _____________________________________________________ Date: __________________
Fourth Respondent's Name: _____________________________________
Title: _________________________________________
Email: ________________________________________ Phone: ____________________
Action Taken (Use additional sheets if needed. Note: List them here and attach copies. Do not submit originals):
Signature: _____________________________________________________ Date: __________________
Vice President for Academic Affairs____________________________________________
Action Taken (Use additional sheets if needed. Note: List them here and attach copies. Do not submit originals):
Signature: _____________________________________________ Date: _____________________________
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ACADEMIC GRIEVANCE FORM A student who wishes to (Dillard University)

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Completed 19 August 2020

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