Fillable ACC Complaint Form Guiding Principles The College District (Alvin Community College)

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ACC Complaint Form Guiding Principles The College District (Alvin Community College)

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ACC Complaint Form
Guiding Principles
The College District encourages students to discuss their concerns with the appropriate instructor or other campus
administrator who has the authority to address the concerns. Concerns should be expressed as soon as possible to allow
early resolution at the lowest possible administrative level. Informal resolution shall be encouraged but shall not extend
any deadlines in this policy, except by mutual written consent.
For more detailed information regarding complaints and course grade complaints, see ACC’s policy, FLD and FLDB.
Complainants may also review information at: Texas Administrative Code, (19 Administrative Code Chapter 1,
Subchapter E).
To file a complaint with Alvin Community College, complete this form and email to Dr. Jade Borne, Vice President of
Student Services and Title IX Coordinator.
Email to vpofstudentservices@alvincollege.edu. (After entering your information, remember to “save as” a PDF
file before emailing)
If you are unable for any reason to complete this form and would like to make a verbal complaint, please send an email
to vpofstudentservices@alvincollege.edu to schedule an appointment.
__________________________________________________________________________________________________
Date: ________________
COMPLAINANT INFORMATION
Last Name: _____________________First Name: ______________________ACC Student ID #: _____________________
Mailing Address: ____________________________________________________________________________________
Phone Number: ______________________ ACC Email Address: ______________________________________________
NATURE OF COMPLAINT
1. Complaint alleging sexual harassment, including sexual violence, is a form of sex discrimination and is therefore
prohibited under Title IX. Unwelcome sexual advances, requests for sexual favors, and other verbal, nonverbal
or physical conduct of a sexual nature constitute sexual harassment. (See ACC Policy FFDA)
2. Complaint alleging bullying, discrimination or harassment based on race, color, sex, gender, national origin,
disability, age or religion. (See ACC Policy, FFE, FFDA and FFDB)
3. Complaint concerning retaliation relating to discrimination and harassment. (See ACC Policy, FFDA and FFDB)
4. Complaint concerning disciplinary decisions. See ACC Policy, FMA)
5. Complaint concerning a commissioned peace officer who is an employee of the College District. (See ACC Policy,
CHA)
6. Complaint concerning grades. (See ACC Policy, FLDB)
7. Complaint concerning the withdrawal of consent to remain on campus. (See ACC Policy, GDA)
8. Other
DESCRIPTION OF COMPLAINT: Describe your complaint in detail. Be sure to include names of parties involved, location,
date and time of event, personnel or facility that you are referring to etc.
PREVIOUS ACTION: Have you brought this matter to the attention of any other individual or department at the college?
If so, please list the name(s) and department(s) of all other persons with whom you have discussed this matter
WITNESSES TO THE INCIDENT (if applicable)
Name: ______________________Title/Relationship: _______________________Phone Number: __________________
Name: ______________________Title/Relationship: _______________________Phone Number: __________________
Name: ______________________Title/Relationship: _______________________Phone Number: __________________
DECLARATION
I verify that the statements made in this form are true and correct to the best of my knowledge.
E-Signature: _____________________________________________ Date: ___________________
Remember to “save as” a PDF file and submit the saved file to vpofstudentservices@alvincollege.edu
Note: Although the college cannot commit to keeping a complaint confidential because of the college’s obligation to
investigate, the college will use its best efforts not to disseminate information concerning the complaint beyond those
who have a need to know.
Rev. 4/2020 VPSS
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RESOLUTION OF COMPAINT (for ACC use only)
COMPLAINT REVIEWED BY (ACC Employee(s)
E-Signature: _____________________________________________ Date: ___________________
E-Signature: _____________________________________________ Date: ___________________
E-Signature: _____________________________________________ Date: ___________________
E-Signature: _____________________________________________ Date: ___________________
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ACC Complaint Form Guiding Principles The College District (Alvin Community College)

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Completed 27 July 2020

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