EQUAL OPPORTUNITY INSTITUTION
Serving Richmond and Scotland Counties
Student Formal Complaint Form
Student Information:
Name: _______________________________________________________________________
Student ID: ___________________________________________________________________
Address: _____________________________________________________________________
City: _______________________________________ State: _________ Zip: _____________
Phone: _______________________ Cell: __________________________
Email: _______________________________________________________________________
Complaint Information:
Complaint filed against: Student ☐ Faculty ☐ Staff ☐
Name: _______________________________________________________________________
Incident Date: _____________________ Incident Time: _______________________
☐ A.M. ☐ P.M.
Incident/Complaint Details (attach additional sheets if necessary)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Have you attempted to resolve the situation? Yes ☐ No ☐
What specific actions, if any, have you taken to resolve the situation?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What specific remedies/actions do you suggest to resolve the situation?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Student Signature: __________________________ Date: _________________________
Received By: ______________________________ Date: _________________________
