STUDENT COMPLAINT FORM
Student Name: ________________________________________________________________________
Student ID B#: ___________________Term: __________________ Course: ______________________
Address: _____________________________________________________________________________
City: _________________________________________________________________________________
Phone: ______________________________ Email Address: ___________________________________
Nature of Complaint:
Academic Safety Faculty Member Staff Member
Other (If other, please explain) ____________________________________________________________
Name of individual and or department
against whom the complaint is filed: ________________________________________________________
Have you spoken directly to the faculty or staff member? Yes
If faculty, have you spoken to the department chair? Yes
No
No
Describe your complaint in detail. Be factual. Use names, dates, and other specific information. Describe
actions you have taken, if any, to resolve the issue. Use the reverse side or attach additional sheets if
necessary.
The information given in the complaint is true and accurate to the best of my knowledge.
Student Signature: ________________________________________ Date: _______________________
Submit this form to any campus Associate Provost or Dean, or submit online: login to myEFSC > Student
Document Dropbox > select Associate Provost/Dean (or Eastern Florida Online) > upload.
Received by (print name): ________________________________________________________________
Signed: ___________________________________________________ Date: ______________________
SC-116-R102919
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