Revised and approved by Faculty Senate on December 4, 2019
1
Southern Connecticut State University
Grade Appeal Form
LEVEL 1 (Department Chairperson / Program Director)
PART 1: Original Appeal
To be completed by the Student and submitted to the Instructor and the Instructor’s Department
Chairperson / Program Director after the Student has communicated with the Instructor. To read the Grade
Appeal Policy & Procedure in full, please review Catalog.SouthernCT.edu (section: Academic Standards).
Name: (Last) __________________________________ (First) ________________________ (M.I.) ___
Student ID:
Course Department Code: ______________ Course Number: _______________ Section:______________
Indicate semester course taken: FALL_____ SPRING_____ SUMMER_____ WINTER_____
Year course taken: _____________ Instructor: ________________________________________________
CHAIRPERSON SIGNATURE* ___________________________________ Date: __________________________
*Signatures from both parties signify that the Student and Chairperson / Program Director have met and discussed the
grade appeal, and that the Chairperson / Program Director shall initiate mediation efforts with the Instructor or render a
decision in the case of an Absent Instructor. In cases, where the Chairperson / Program Direc
tor is the Instructor of the
course, and the Student is moving directly to a Level 2 appeal, no signature from the Chairperson/Program Director is
required.
Explain below, in detail, why you think a palpable injustice has occurred. Refer to the definition of palpable injustice in
item I (page 1) of the Grade Appeal Procedure Document. Please also attach any relevant documentation. Use
additional sheet on page 4 if necessary:
STUDENT SIGNATURE*________________________________________ Date: __________________________
Note: Students may create a digital ID using their SCSU email by clicking the signature block above, or the form may be
accepted as an attachment from their SCSU email without a signature.
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Revised and approved by Faculty Senate on December 4, 2019
2
Southern Connecticut State University
Grade Appeal Form
LEVEL 1 (Department Chairperson / Program Director)
PART 2: Documentation of Outcomes
To be completed by the Department Chairperson / Program Director after mediation efforts with the
Instructor have been completed or after the Chairperson / Program Director has rendered a decision in the
case of an Absent Instructor. The Chairperson / Program Director must return the completed form to the
Student and provide copies to the Instructor and the Dean of the Instructor’s school or college.
1. Document Chairperson’s / Program Director’s efforts to mediate the grade dispute (e.g. date or dates of contact
and/or discussion, etc.). In the case of an Absent Instructor, indicate this.
2. Was a resolution reached? (Check one) YES NO
3. Provide a summary of grade appeal decision. If resolution not reached, the Student may proceed to Level 2. (Use
additional sheets if necessary.)
Grade Prior to Appeal ____________ Grade Following Appeal (if changed) ____________
STUDENT SIGNATURE*_________________________________________ Date: ____________________________
Note: Students may
create a digital ID using their SCSU email by clicking the signature block above, or the form may be
accepted as an attachment from their SCSU email without a signature.
INSTRUCTOR SIGNATURE* ______________________________________ Date: ____________________________
CHAIRPERSON SIGNATURE* _____________________________________ Date: ____________________________
*Signatures from all three parties signify that the Chairperson’s / Program Director’s mediation efforts have
been completed and have c
ulminated either in an agreement by the Instructor to change the grade or in a denial of the
appeal. In cases of an Absent Instructor, no Instructor signature is needed. In cases where the Chairperson / Program
Director is the Instructor of the course and the Student is moving directly to a Level 2 appeal, no signature from the
Chairperson /Program Director is required.
NOTE: All parties shall retain copies of this completed form and supporting documentation.
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Revised and approved by Faculty Senate on December 4, 2019
3
Southern Connecticut State University
Grade Appeal Form
LEVEL 2 (University Academic Standing Committee)
To be submitted, along with already completed pages (Original Appeal and Documentation of Outcomes
from Level 1, and any supporting documentation), to the Faculty Senate President, who shall forward it to
the University Academic Standing Committee and the Dean of the appropriate school or college.
(To be completed by Student)
1. Date of grade appeal submission to Faculty Senate President: (dd) \ (mm) \ (yr)
(To be completed by Faculty Senate President)
2. Date grade appeal received from Student: (dd) _____ \ (mm) _____ \ (yr) _____
3. Date grade appeal forwarded to UASC and to relevant Dean: (dd) \ (mm) \ (yr)
(To be completed by UASC)
4. Provide a written rationale of UASC grade appeal decision. (Use additional sheets if necessary.)
SIGNATURE OF UASC CHAIRPERSON(S) ____________________________________________________________
SIGNATURE OF UASC CHAIRPERSON(S) ____________________________________________________________
Date of Grade Appeal Final Decision: (dd) _ \ (mm) ______\ (yr) ____
Grade Prior to Appeal: Grade Following Appeal:
Date Grade Change Submitted to Registrar (if applicable): (dd) _____ \ (mm) _____ \ (yr) _____
Date Decision and Written Rationale Sent to Student, Instructor, Department Chairperson / Program Director, and
relevant Dean: (dd) _____ \ (mm) _____ \ (yr) _____
NOTE: All parties shall retain copies of this completed form and supporting documentation.
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Continued from Page 1: Explain below, in detail, why you think a palpable injustice has occurred. Refer to the
definition of palpable injustice in item I (page 1) of the Grade Appeal Procedure Document. Please also attach
any relevant documentation.
Southern Connecticut State University
Grade Appeal Form
LEVEL 1 (Department Chairperson / Program Director)
PART 1: Original Appeal
ADDITIONAL SHEET
4
NOTE: All parties shall retain copies of this completed form and supporting documentation.