Rev. 8/2022
Student Grievance Form
This Student Grievance Form provides guidance for students in following the grievance process for academic and non-
academic grievances, and complaints of unlawful discrimination or unfair treatment. Use this form to document your
grievance. This form also serves as the written grievance for Level Two and Level Three, though it is possible to resolve your
grievance without going through all three levels. For information about where to submit this form, please refer to the full
Student Grievance process at https://www.nvcc.edu/policies/_files/608-Student-Grievances.pdf.
Name: NOVA Student ID#:
Address: Work Phone:
Home Phone:
Email: @email.vccs.edu Cell Phone:
Respondent, the person against whom the grievance is made: ________________________________
Please indicate the type of grievance(Check all that apply): Non-academic Academic
Discrimination
In the space below, state your grievance. Be as specific as possible. If this is an academic grievance (including a grade
appeal), please give the faculty’s name, course name, and number. Please identify any specific policy or procedure you
believe was applied to you unfairly, or the basis for any claim of unlawful discrimination against you (for example, race, sex,
disability, etc.). If you need additional space, please attach a brief statement.
If you have attached any documents to this form, please list them in the space below and indicate how they support your
grievance.
In the space below, please state the remedy you are seeking.
