TN eCampus – Grade Change Form
St
udent Last Name: ________________________________ Student First Name: __________________________
Student Home Institution: ___________________________ Student ID: _________________________________
Student ID is filled out by home institution
Subject Area: __________ Course #: __________ Hrs Credit: __________
Semester: __________ Year: __________ Change grade: from ______ to ______
Instructor Last Name: ______________________________ Instructor First Name: _________________________
Instructor Email: __________________________________ Instructor Phone: ____________________________
Dept Chair Email: __________________________________ Dept Chair Phone: ____________________________
Dean Email: ______________________________________ Dean Phone: ________________________________
Reason for Grade Change [
radio buttons below]
Computational error
Grade transposition
Instructor missed deadline for turning in “incomplete” grade form to the Office of Records
Student missed final exam due to per
sonal or immediate family physical illness or accident
Request to change a previously assigned grade to a “W” (documentation of extenuating circumstances must
be attached)
Incorrect grade assignment because of name change or student ID number change
Other (explain in “Comments” section)
Comments: _____________________________________________________
Signatures
Follow grade change procedures at your institution for signatures.
Scan and attach this form to email or fax to student’s home institution. No signature stamps.
Ins
tructor Name (print or type): ____________________________________________
Instructor Signature: _____________________________________________________ Date: _____________
Dept Chair / Dean Name (print or type): _____________________________________
Dept Chair / Dean Signature: ______________________________________________ Date: _____________
Campus Contact Signature at Instructor Institution: ____________________________ Date: _____________
Campus Contact Signature at Receiving Institution: _____________________________ Date: _____________
Processed in Registrar’s Office by: __________________________________________ Date: _____________
Updated: 2/22/16
click to sign
signature
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click to sign
signature
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click to sign
signature
click to edit
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click to sign
signature
click to edit
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