Fillable STUDENT APPEAL FORM Appeals will only be accepted (Eastern Florida State College)

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STUDENT APPEAL FORM Appeals will only be accepted (Eastern Florida State College)

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STUDENT APPEAL FORM
Appeals will only be accepted within 2 years from when you took the course for which you are appealing.
PLEASE PRINT
Student Name:
Address:
City: State: Zip:
Telephone Number: Student ID B#
Student Email Address:
Course (s) Appealing:
Instructor(s) Name: Term:
Check box if receiving VA benefits. ☐
Student Signature: Date:
Please read both sides of this form carefully and follow the procedures in the order they are listed.
All appeals must be accompanied by full documentation (i.e. schedule, billing statement, physician’s note, employer letter, etc.)
justifying the student’s request. These procedures must be followed before an appeal may be submitted.
Incomplete appeals will be returned to the student for completion.
T
here are two types of appeals. Determine which best describes your circumstances (situation) and follow the procedures for
that type of appeal.
I. Academic Appeal: Issues with the instructor, classmates, course content and/or delivery, grades, etc. Complete Steps 1 and 2.
II. Administrative Appeal: Issues with the administration, registration, late withdrawals due to medical problems, or other
extenuating circumstances (documentation required).
Complete the appeals process with Steps 1.
The Associate Provost/Dean will notify you in writing of his/her decision. If not satisfied with
the resolution, you may request in writing,
through the Associate Provost/ Dean's office, a review by the Associate Provost/Dean’s immediate supervisor. The request must be
received within ten days of student notification of the resolution and must contain additional documentation that is pertinent to the
appeal. The decision of the Provost or supervisor is final.
If you feel that the established procedures were violated, you may request an administrative review by the Vice President of Academic &
Student Affairs/CLO. This is NOT a re-trial of the incident, but a procedural review. The request for administrative review must be made in
writing through the Associate Provost/Dean’s immediate supervisor within five days of receiving notification of the resolution. The
decision of the Vice President is final.
1. I am requesting (be specific): _
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
SC-074A R051519
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2. My reason(s) for making this request (be specific): ___________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Attach additional pages if necessary. Consult student handbook for additional information.
Meet with the instructor and attempt to resolve the issue. If appeal for grade change is approved, submit the Grade Change Form
through regular channels Request Approved
☐ Request Denied ☐
Instructor Signature and Date: _________________________________________________________________________________
Meet with the department chair on the same campus. If appeal for grade change is approved, submit the Grade Change Form
through regular channels. Request Approved
☐ Request Denied ☐
Department Chair/Program Manager Signature and Date: ___________________________________________________________
For all appeals that cannot be resolved at the instructor or department chair level, submit this Student Appeal Form, with full
documentation attached, to the Campus Associate Provost or Dean for review. Request Approved
☐ Request Denied ☐
Campus Associate Provost/Dean Signature and Date: ________________________________________________________________
RESOLUTION: _________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Eastern Florida State College is dedicated to providing a nondiscriminatory environment which promotes equal access, equal educational opportunity
and equal employment opportunity to all persons regardless of age, race, national origin, color, ethnicity, genetics, religion, sex, gender preference,
pregnancy, disabilities, marital status, veteran status, ancestry or political affiliation in its programs, activities, or employment.
Inquiries regarding the College’s nondiscrimination
policies may be directed to:
M
s. Darla Ferguson, Chief Equity and Diversity Officer
Cocoa Campus, Building 2, Room 103
1519 Clearlake Road, Cocoa, FL 32922
Phone: 321-433-7080 E-mail: fergusond@easternflorida.edu
OR
Lt. Mark Renkens, Security & Title IX Compliance Coordinator
Melbourne Campus, Bldg. 10, Rm. 215
3865 North Wickham Road, Melbourne, FL 32935
Phone: 321-433-7180 Fax: 321-433-5026
renkensm@easternflorida.edu
Inquiries regarding veterans’ programs may be directed to:
Military & Veterans Service Center
Student Services
Center/Administration Building 1, Room
140 3865 N. Wickham Road, Melbourne, FL 32935
Phone 321-433-7880
OR
Military & Veterans Service Center
Ralph M. Williams Student Center, Building 11, Room 113
1519 Clearlake Road, Cocoa, FL 32922
Phone: 321-433-7880
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STUDENT APPEAL FORM Appeals will only be accepted (Eastern Florida State College)

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Completed 21 July 2020

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