MT. SAN JACINTO COLLEGE
ACADEMIC ASSISTANCE REQUEST FORM
Student Information
Name: ______________________________________________________________________________
Student ID: __________________________________________________________________________
MSJC E-mail Address: ________________________________________________________________
Phone number: _______________________________________________________________________
Course Information
Course Name and Number: _____________________________________________________________
Section #: ___________________________________________________________________________
Instructor: ___________________________________________________________________________
Have you contacted the instructor directly regarding your concern?
Have you contacted the Department Chair directly regarding your concern?
If No, why not? If Yes, describe the outcome of that contact.
Assistance Request Information
Describe your concern in detail. Specify all pertinent dates, people involved, and the substance of your
concern. Attach any documentation that helps describe and/or substantiate your concern (e.g. course
syllabus, college policies, etc.).
Updated 12.2020
Yes
Yes
Updated 12.2020
Desired outcome to resolve your concern:
Witnesses who can substantiate your concern: (if applicable)
1. ______________________________________________________________________
2. ______________________________________________________________________
3. ______________________________________________________________________
The undersigned affirms that the information provided is true and correct to the best of his or her
knowledge. He or she also acknowledges that the information provided will be used in efforts to resolve
the concern and will be shared with persons contacted as part of that process.
________________________________________________ _________________________________
Signature Date
Please allow at least one week for processing. For status of your submission, feel free to contact the
Office of Instruction at Instruction@msjc.edu.
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Updated 12.2020
OUTCOME SUMMARY
Outcome summary to be completed with the final resolution by the department chair or dean and
submitted to the Office of Instruction for communication to the student, if needed.