College of Health and Human Services
Professional Behavior Violation Appeal Request
Student ID #:
Disciplinary Action appealed:
Grounds for appeal (check one and give rationale below):
Procedural errors related to the Program’s established policies have substantially affected the
dismissal determination
New and significant information has become available that could not have been discovered or
provided by a properly diligent student during the review at the School and/or Program level
By signing this form, I give permission for all materials from the Program and/or School appeals
process to be forwarded to the Professional Behavior Committee panel for review.
Student Signature Date