APPEAL OF
Academic Dismissal
Appeal must be submitted within 10 calendar days of dismissal
Date:
Month Day Year
Dismissal Year: Quarter: Summer Fall Winter Spring
Student Name:
Last First M.I.
Student ID#: Email:
Address:
Street Apt.# City State Zip
Phone number (daytime):
Name of Completion Coach or Counselor:
Last First
In order to request an appeal of academic dismissal you must provide documentation of extraordinary or extenuating circumstances
that prohibited you from being academically successful. You are responsible for providing complete and accurate information.
Failure to provide this information will result in an automatic denial of the appeal.
Directions:
1. Within 10 calendar days of your dismissal, complete this form and submit it with a letter addressed to Lane Schumacher,
Associate Dean for Student Retention & Completion. In the letter, clearly describe the extraordinary or extenuating circumstances
that prohibited you from being academically successful since the time you were placed on “subject to dismissal” status.
2. Include with your letter, any documentation or evidence to support the extraordinary or extenuating circumstances that are
described in your letter. For example, medical or health-related circumstances require some documentation from a healthcare
provider or healthcare institution; legal problems require information from an attorney or from court personnel; etc. Personal
issues such as work schedules, childcare problems, etc. are not generally considered extraordinary or extenuating and
probably will not result in approval of an appeal.
3. Mail information to Lane Schumacher, Associate Dean for Student Retention & Completion, Columbia Basin College, 2600
N. 20
th
Ave., MS-H8, Pasco, WA 99301-3379.
4. Your information will be reviewed and one of the following actions taken:
Your request for an appeal is denied; the information you submitted does not justify an appeal.
More information is needed; contact Lane Schumacher by calling (509) 542-4595.
Your request for an appeal is approved. Upon reinstatement you must receive no less than a 2.00 quarterly GPA, or
you will be dismissed from Columbia Basin College without the right to appeal.
Year/Quarter student may return to Columbia Basin College:
Year: Quarter: Summer Fall Winter Spring
Student Signature:
Date
Reviewers’ Signatures:
Oce Use Only
Date appeal received
month day year
Columbia Basin College complies with the spirit and letter of state and federal laws, regulations and executive orders pertaining to civil rights, Title IX, equal opportunity and afrmative action. CBC does not discriminate on the basis of race, col-
or, creed, religion, national or ethnic origin, parental status or families with children, marital status, sex (gender), sexual orientation, gender identity or expression, age, genetic information, honorably discharged veteran or military status, or the
presence of any sensory, mental, or physical disability, or the use of a trained dog guide or service animal (allowed by law) by a person with a disability, or any other prohibited basis in its educational programs or employment. Questions or com-
plaints may be referred to the Vice President for Human Resources & Legal Affairs and CBC’s Title IX/EEO Coordinator at (509) 542-5548. Individuals with disabilities are encouraged to participate in all college sponsored events and programs.
If you have a disability, and require an accommodation, please contact CBC Disability Support Services at (509) 542-4412 or the Washington Relay Service at 711 or 1-800-833-6384. This notice is available in alternative media by request.
