Student Complaint/Grievance Form
Instructions
: A grievance is an educational or personal issue or condition that a student believes to be unfair, inequitable,
discriminatory, or a hindrance to his/her education. Students who have a complaint or grievance about their Tarrant County College
experience should complete this form and submit it to the campus department where complaint originated. Students should allow
10 business days to receive a written response to their complaint or grievance.
Student Information
Student Name:
Email Address:
Cell Phone Number:
Work Phone Number:
Home Phone Number:
Semester & Year: Student ID#:
City/State/Zip:
Address:
Complaint/Grievance Information
Retaliation against an individual filing a grievance is strictly prohibited and constitutes a violation of college policy which may result
in disciplinary action, including dismissal/expulsion.
Name of individual and/or department against whom the complaint/grievance is filed:
Describe your complaint/grievance in detail. Include date/s of occurrence (be as specific as possible). Attach additional sheets, if
necessary, along with any documentation that will help describe and substantiate the complaint. Are there any witnesses who
should be interviewed? If yes, list names and contact information.
Students are encouraged to discuss their concerns and complaints through informal conferences with the appropriate instructor or
campus administrator. Have you made an attempt to resolve this complaint or grievance with the individual and/or department
involved?
Yes No If yes, describe the outcome: (Attach any additional comments, if necessary)
What outcome do you hope to achieve after talking to the appropriate college official(s)? Attach additional sheets, if necessary.
I understand that information contained in the grievance form will be held confidential to the extent possible. Grievance
information may be shared with college officials in order to conduct a thorough investigation. 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 with college disciplinary policies.
Signature:
Student
Date:
Revised: June 2011
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Grievanceflowchartandresponsetoincident
Forofficeuseonly:ActionTakenbyadministrator(IncludeLevelONE,TWOorotherdocuments):
Grievancewasresolved:YesNo
Ifnotresolved,whatarethenextrecommendedsteps? 
Administratorsignature:Date:
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