Fill - Free fillable STUDENT COMPLAINT FORM (Citrus College) PDF form

Office of the Vice President of Student Services

1000 W. Foothill Blvd., Glendora, CA 19741-1885  (626) 914-8532, Student Services Building, SS 218

STUDENT COMPLAINT FORM

Student Name: ____________________________________________________________________________

Student ID Number: __________________________________ Email: __________________________________

Mobile Phone: __________________________________ Home Phone: ___________________________

Street Address: __________________________________

City: __________________________________ Zip Code: ______________________________

NOTE: If you have a complaint relating to course grades or the right to free expression, please complete the Student Grievance

Form.

Please explain below or attach a type-written, detailed explanation of your complaint. Explain as clearly as possible why

you are filing a complaint. Be sure to include all the necessary information (including names, dates, etc.) to support your

statements so that your complaint can be appropriately addressed. Please complete and submit this form to the office

or department where the incident occurred.

Please type the name of the employee that is involved in your complaint (if applicable):

Employee Name: __________________________________ Date of Incident: ________________________

Department/Office: ________________________ Department Phone: _____________________

Desired Outcome

STUDENT SIGNATURE:________________________________________ DATE: ___

_____________________

Office of the Vice President of Student Services

1000 W. Foothill Blvd., Glendora, CA 19741-1885  (626) 914-8532, Student Services Building, SS 218

FIRST LEVEL – FOR OFFICE USE ONLY

Date Received: ________________________

Result/Outcome:

 Informal resolution, met with student

 Forwarded to instructor for resolution

 Student did not request action, just be heard

 Complaint involved grades and/or freedom of expression. Student was directed to follow the Grievance process.

 Complaint involved sexual, harassment, discrimination, violence, or stalking and was forwarded to the Title IX

Coordinator in Human Resources on:

 Other (explain):

Manager Name: ________________________ Extension: ________________________

Signature: ___________________________________________ Date: ________________________

IF necessary, forward information to second level administrator (i.e. Dean or Vice President)

SECOND LEVEL – FOR OFFICE USE ONLY

Date Received: ________________________

Result/Outcome:

Name: ________________________ Extension: ________________________

Signature: ___________________________________________ Date: ________________________

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