Problem Resolution Form
Date Rcvd: Intl:
Use this form to aid in resolving problems with a CCC policy, staff or faculty member. Refer to the current Student Handbook
for detailed Problem Resolution Procedures. This form should be returned to the appropriate department supervisor or to the
Associate Dean of Academic Foundations and Connections in the Dye Learning Center, room 142.
Name of Person Reporting Problem
Name: ___________________________ CCC ID Number: _____________________ Date: _____________ Phone:__________________________
Did you speak with the person involved in the incident prior to filling out this form? Yes No
If yes, describe the informal process you used and the outcome.
If no, please state why an informal discussion about the issue did not take place.
Please include the name (s) of those involved.
ease describe the incident in as much detail as possible, include names and other important infor-
Reference CCC’s policies and procedures in the Student Handbook as they apply.
Attach a separate page if needed.
Date of Incident:____________________________ Time:_____________________________
Campus:___________________________________ Building:_________________________
Please describe, as clearly as you can, what you believe would be the best solution to this problem.
Reference CCC’s policies and procedures in the Student Handbook as they apply.
Attach a separate page if needed.
tatement of Understanding:
Please read and initial all of the following to acknowledge that you understand Clackamas Community College’s
Disciplinary Appeal Procedures.
______ I have read CCC’s Problem Resolution Procedures in the current academic year’s Student Handbook.
______ I understand that this form must be submitted to the appropriate supervisor or associate dean within thirty
(30) working days of the end of the term in which the problem occurred.
______ I understand the importance of maintaining confidentiality and respect for all parties involved during the
Appeal Process.
______ I have completed the Problem Resolution Form in its entirety and the statements herein are true and
______ I understand that the associate dean or supervisor will gather necessary evidence to make a decision,
and this may require me, the student, to meet with the staff member involved at the associate dean or
supervisor’s request.
______ I understand that after the associate dean or supervisor has decided upon the outcome, s/he will provide
me, the student, a written explanation of the decision within ten (10) working days of the receiving the
Problem Resolution Form.
_______ ______________________________ ___________________________________________ __________________
Printed Name Signature Date
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