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Martin Community College
Grade Appeal Form
Before submitting this form with your documentation, please make sure to read the Grade
Appeal Policy and Procedures in the MCC Catalog. There are steps that must be followed before
submission of this form and the necessary documentation.
Student Name: ___________________________________ Student ID Number: __________
Name of Course for Grade Appeal: ___________________ Semester: __________________
Instructor Name: _________________________________
Date of Consultation with Faculty Member (required step): _____________________________
Date of Consultation with Department Chair (required step): ____________________________
Attestation: I, _________________________, attest that the information provided in this form
and the attached documentation is accurate and reflects the events to the best of my
knowledge from my perspective.
_________________________________________ ________________________
Student Signature Date
Please check the grounds for which grade is being disputed:
☐ The course grade was assigned in a manner not consistent with the standards and
procedures for evaluation established by the instructor, at the beginning of the course in the
course syllabus but supplemented on occasion during the semester in other clearly
documented communication directed to the class.
☐ The course grade was based upon the student’s race, color, creed, national origin, sex, age,
sexual orientation, disabling condition, or other personal characteristics, or for some other
arbitrary or personal reason unrelated to the instructor’s exercise of his or her professional
academic judgment in the evaluation of the academic performance of the student.
☐ The course grade assigned by the instructor was the result of a clear and material mistake in
calculating or recording grades.
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