Student Appeal Form
Instructions: Students who wish to appeal a decision relating to a complaint or grievance should complete this form and
submit it to the appropriate instructor, campus, or district administrator. Students should allow 10 business days to
receive a written response to their appeal.
Student Information
Student Name:
Email Address:
Cell Phone Number:
Work Phone Number:
Home Phone Number:
Semester & Year: Student ID#:
City/State/Zip:
Address:
Initial Complaint/Grievance Information
Name of individual and/or department against whom the complaint or grievance was filed:
With whom was the initial complaint/grievance filed? How was it resolved? Describe any additional issues that should be addressed.
(Use and attach additional sheets if necessary.)
What is the desired outcome after talking to the appropriate college official(s)? (Use and attach additional sheets if necessary.)
I declare that it has been no more than 10 days since the receipt of a written lower level response or the
expiration of the response deadline and hereby request a Level 2 3 appeal. I understand that the proper
administrator will hold a conference within 10 days after this appeal notice is filed, and the conference will be
limited to the issues that I presented at the previous level and any other issues presented in this document. I
understand that the administrator may set reasonable time limits for the conference and will provide me a
written response within 10 days following the conference setting forth the basis of the decision.
I hereby declare that the information on this form is true, correct and complete to the best of my knowledge. I
understand that any misrepresentation of information may result in disciplinary actions, in accordance college
policies and regulations.
Signature of student:
Date:
RESET
Grievanceflowchartandresponsetoincident
Forofficeuseonly:ActionTakenbyadministrator(IncludeLevelONE,TWOorotherdocuments):
Grievancewasresolved:YesNo
Ifnotresolved,whatarethenextrecommendedsteps? 
Administratorsignature:Date:
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