Fillable Complaint Form (Alvin Community College)

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Complaint Form (Alvin Community College)

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ACC Complaint Form
G
uiding 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 deliver to Marilyn Dement, Vice President of
Student Services.
Email to vpofstudentservices@alvincollege.edu
Deliver in person to A100 (Admissions Office)
Mail to: ACC Admissions Office, 3110 Mustang Road, Alvin, TX 77511
Fax to: 281-756-5812
If y
ou are unable for any reason to complete this form and would like to make a verbal complaint, please call 281-756-
3517 to schedule an appointment.
D
ate: ________________
COMPLAINANT INFORMATION
L
ast Name: __________________First Name: ___________________Student ID: __________________________
Address: ____________________________________________________________________________________
Phone Number: ______________________ Email Address: ____________________________________________
NATURE OF COMPLAINT
1.
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)
2
. C
omplaint concerning retaliation relating to discrimination and harassment. (See ACC Policy, FFDA and FFDB)
3
. C
omplaint concerning disciplinary decisions. See ACC Policy
, FMA)
4. Complaint concerning a commissioned peace officer who is an employee of the College District. (See
ACC
Policy, CHA)
5
. C
omplaint concerning grades. (See ACC Policy
, FLDB)
6. Other (please specify)
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.
Signature: __________________________Printed Name: ___________________________Date:___________________
Your email address is in lieu of your signature if this complaint is filed via email.
Click here to auto-submit.
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.
RESPONSE(S) BY ACC PERSONNEL
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Complaint Form (Alvin Community College)

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Completed 25 July 2020

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