Student Originated Request for Change of Grade form Page 1
Student Originated Request for Change of Grade
In accordance with Academic Policy AA-03-020 I am submitting this Student Originated
Request for Change of Grade. I understand that this form must be filled out on a
computer and printed out. No hand written requests will be accepted.
Deadlines: Appeals of fall semester grades must be submitted within the first two
weeks of the following spring semester. Appeals of spring and summer semester
grades must be submitted within the first two weeks of the following fall semester.
Student Details
Student Name: _________________________________________________
Student ID Number: _____________________
Date of Request: _______________
Course Information
Name of Course: ______________________________________________________________
Catalog Course Number and Section (e.g., NAU 101-3): ______________________________
Four-digit Course Number: ________
Is this an STCW course?
Yes
No
Semester and Year in which course was taken:
Fall _______
Spring _______
Summer _______
Instructor of Record: ________________________________________________
STCW Assessor (if different from instructor of record: ________________________________
Grade assigned: _______________
Grade requested: ______________
Reason for grade appeal (check all that apply):
Instructor Mistake
Instructor Incompetence
Instructor Bad Faith
Instructor Unfairness
Third Parties/Witnesses you intend to call who can support your case:
____________________________________________________________________________
Please attach the following documents:
A narrative description of the circumstances surrounding the assigned grade and why
you feel it was inappropriate. You must support your claim of instructor mistake/bad
faith/incompetence/unfairness and provide support for the grade or remedy you
propose.
Student Originated Request for Change of Grade form Page 2
Course syllabus
Pertinent assignments, examinations, etc.
Any other documents which are pertinent to your grade appeal, as well as documents
supporting the grade or remedy you are requesting.
Instructor Provided with Copy of the Grade Appeal Request
I (print your name) ___________________________________ certify that I have provided
the instructor of record and/or involved assessor with a copy of this grade appeal request.
Signed: __________________________________________
Date: ___________________
Provisional Enrollment in Follow-on Courses
If the disputed grade is the sole cause preventing you from enrolling in any follow-on courses,
for which the disputed course/grade/assessment is a pre-requisite, list the follow-on courses
in which you intend to provisionally enroll, using the course catalog number:
____________________________________________________________________________
Provisional Enrollment Agreement:
I (print your name) ___________________________________understand that I am being
allowed to provisionally enroll in the courses listed above, and will be allowed to stay
enrolled and receive a grade and credit for the above courses only if my grade appeal results
in the pre- requisites for the above listed courses being met. Should my grade appeal not
result in my meeting course pre- requisites, I understand I will be dis-enrolled from the
courses in which I was provisionally enrolled and assigned a grade of “W”, regardless of my
progress, grade, or completion in the follow-on courses. A grade of “W” is an “authorized
withdrawal and will not negatively impact my GPA but may impact current or future financial
aid. I understand it is my responsibility to determine any potential financial impacts that may
result from withdrawal from courses.
Signed: __________________________________________
Date: ____________________