FORMAL APPEAL: The grade dispute is unresolved. I am proceeding with the formal appeal process.
Name: Date:
Student ID/SSN Phone:
Street Address:
City: State: Zip:
Course Prefix & Number: Course Title:
Instructor Name: Term Course Was Taken:
Student’s Statement: Following the provisions of the Student Grade Appeal Process, I am appealing the
grade of _____ that I received in the course cited above.
A. As part of the informal appeal process:
I met with the instructor on __________ _______________________________
Date Instructor/Designee Signature Date
The instructor is no longer available
B. I met with the Department Chair or designee on _______ ________________________________
Date Department Chair/Designee Signature Date
I choose to bypass the formal process.
STEP 1: Student’s Written Statement and basis for this appeal is (Check all that apply)
____ Mistake ____ Incompetence ____ Bad faith ____ Fraud
I have attached my statement describing the basis for my appeal (required). _________________________
Student Signature Date
I have met with the Division Dean. Results of this meeting: Resolved Unresolved
_______________________________________________ ____________
Dean/ Designee Signature Date
A copy of this form and attachments were provided to the instructor or in the instructor’s absence, the department
chair or designee by the Division Dean or designee on ____________ (Date).
If the grade appeal is unresolved after Step 1, the student may proceed to Step 2 within 5 works days of meeting
with the Division Dean or designee.
STEP 2: Investigation: Date Filed: __________ Results of Investigation: Resolved Unresolved
An investigation shall be conducted within 30 work days of the Step 2 filing date. If the grade appeal is
unresolved after Step 2, the student may proceed to Step 3 within 5 work days of receipt of the determination from
the investigation.
Summary of investigation and findings is attached.
_______________________________________________ ____________
Signature Director of Admissions & Records Date
STEP 3: Hearing: Date Filed: __________ Results of Hearing: Appeal Granted Appeal Denied
Summary of Hearing determination is attached. Student and faculty were notified on ______(date)
________________________________________ __________________
Chair, Grade Appeal Committee Date
Change of Grade Form (if applicable) submitted to Admissions and Records: _________ (date)
Revised 4/16/06